Blood Biomarkers for Monitoring and Prognosis of Large Vessel Vasculitides

[Unclear cause of unilateral blindness with normal inflammation parameters]

A 70-year-old female patient presented with unilateral blindness of the right eye. As C‑reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were inconspicuous, a nonarteritic embolic occlusion was assumed; however, after detailed anamnesis large vessel vasculitis (LVV) appeared more likely, which was confirmed by the subsequent imaging diagnostics. This rare case of LVV without an increase in one of the inflammatory parameters CRP or ESR highlights the importance of the medical history and targeted diagnostic procedures.

Elevated serum 25-hydroxyvitamin D: a potential indicator of remission in Takayasu arteritis patients with normal ESR and CRP levels

OBJECTIVE

The goal of the present study was to investigate the correlation between serum 25-hydroxyvitamin D [25(OH)D] levels and disease remission in Takayasu arteritis (TAK) patients.

METHODS

This retrospective study included 59 patients in the study group and 80 patients in the validation cohort with TAK. After 6 months of therapy, patients were re-evaluated, and serum 25(OH)D levels were compared before and after treatment. Correlations between changes in 25(OH)D levels and changes in disease activity scores (NIH, ITAS2010, ITAS.A) were analyzed. Additionally, a predictive cut-off value for disease remission was determined.

RESULTS

After 6 months of therapy, serum 25(OH)D levels in TAK patients significantly increased compared to baseline [(18.33 ± 7.25)µg/L vs (11.77 ± 4.14) µg/L] (P < 0.001). Positive correlations were observed between the increasing changes in the 25(OH)D level and the decreasing changes in the reduced NIH, ITAS2010, and ITAS.A scores (r = 0.455, P < 0.001; r = 0.495, P < 0.001; and r = 0.352 P = 0.006, respectively). A change of 8.45 µg/L in 25(OH)D level was identified as the predictive cut-off value for TAK remission (sensitivity 54.1%, specificity 90.9%, area under the curve = 0.741). Similarly for patients with normal baseline ESR, sensitivity is 68.0%, specificity is 92.3%, and area under the curve is 0.831, and for patients with normal baseline CRP, sensitivity is 58.3%, specificity is 90.0%, and area under the curve is 0.748. Validation in an additional 80 patients demonstrated a higher remission rate in those with a 25(OH)D level change > 8.45 µg/L.

CONCLUSION

Serum 25(OH)D levels significantly increased after treatment in TAK patients, and an increase of ≥ 8.45 µg/L was predictive of disease remission, especially in individuals with normal baseline ESR and/or CRP levels. Key Points • Following treatment, there was a significant increase in serum 25(OH)D levels among TAK patients. • The elevated changes in 25(OH)D levels before and after treatment demonstrated a positive correlation with the reduction in disease activity scores. • In patients with TAK before and after treatment, an elevation in serum 25(OH)D levels exceeding 8.45 µg/L serves as an indicator for disease remission, particularly prominent in individuals with normal baseline ESR and/or CRP levels.

Analysis of clinical features and prognostic factors in Takayasu arteritis involving pulmonary hypertension: A retrospective study

BACKGROUND

Multiple takayasu arteritis (TA) is a chronic nonspecific large to medium vasculitis disease that mainly accumulates the aorta and its branches. Pulmonary vascular disease is often seen as stenosis and occlusion, and patients may show no moderate to severe pulmonary hypertension (PH). This study aims to summarize the clinical characteristics and analysis of prognostic factors in patients with PH caused by TA.

METHODS

Patients diagnosed with aortitis involving the pulmonary artery by pulmonary arteriography or pulmonary artery and total aortic computed tomography arteriography (CTA). All patients underwent detailed clinical assessment, laboratory data collection, and analysis of imaging data. Patients were followed up and factors affecting the prognosis of the pulmonary arteries were analyzed.

RESULTS

Most of the patients' complaints were chest tightness, shortness of breath, decreased activity tolerance, hemoptysis and chest pain. 56.90% of the patients were in at the time of admission. Echocardiographic estimation of pulmonary artery systolic pressure was 90.39 ± 22.87 mm Hg. In terms of laboratory tests, 39.66%% of the patients had elevated C-reactive protein and erythrocyte sedimentation rate, and amino-terminal natriuretic peptide precursor on admission. In terms of imaging, all patients had pulmonary artery involvement, which was combined with aortic involvement in 31.03%. Nuclide lung perfusion/ventilation imaging of the patients revealed multiple perfusion defects/absences in the segmental and subsegmental distribution of the lungs. Univariate Cox regression model analysis suggested that patients' WHO functional class at admission, age ≧ 51 years at the time of consultation, and amino-terminal natriuretic peptide precursor ≧ 3500 pg/mL were factors affecting the prognosis. Further multifactorial Cox regression model analysis suggested amino-terminal natriuretic peptide precursor ≧ 3500 pg/mL was an independent predictor of poor prognosis with a hazard ratio (HR) value of 5.248.

CONCLUSION

Electrocardiogram and echocardiogram may suggest an increased right heart load; some patients have elevated serum inflammatory indexes. Characteristic imaging manifestations include widening of the main pulmonary artery, multiple pulmonary segmental and subsegmental stenoses.

MRI Diagnosis of Coronary Artery Lesions in Children With Kawasaki Disease and Their Correlation With Inflammatory Factors

BACKGROUND

Ultrasonography (US), as a routine examination for evaluating coronary artery lesions (CAL) in children with Kawasaki disease (KD), has strong subjectivity and limitations. Non-contrast enhanced coronary magnetic resonance angiography (NCE-CMRA) is sensitive and reliable in displaying the segments of coronary arteries (CA).

PURPOSE

To evaluate the CA using NCE-CMRA, to compare NCE-CMRA with US, and to assess the correlation between KD-related inflammatory factors and the occurrence of CAL.

STUDY TYPE

Retrospective.

POPULATION

61 children with KD who had undergone NCE-CMRA. Ultimately, 52 cases were included (32 males and 20 females), with an average of 5.9 ± 0.3 years old.

FIELD STRENGTH/SEQUENCE

3-T, 3D balanced turbo field echo sequence.

ASSESSMENT

NCE-CMRA and US coronary visualization rates were compared in 41 children who were imaged with both techniques. Inflammatory factors were compared between CAL and normal coronary artery (NCA) subgroups. In the CAL group, correlations of these inflammatory factors with CAL parameters were investigated.

STATISTICAL TESTS

Comparison between groups was performed by the two independent samples t-test; the comparison of enumeration data between groups was performed by chi-square test. Receiver operating characteristic (ROC) curve analysis was performed to determine the sensitivity of inflammatory factors for detecting CAL. The correlation between CAL and inflammatory indexes was analyzed by multiple linear regression. A P value <0.05 was considered statistically significant.

RESULTS

NCE-CMRA visualized significantly more segments than US (76% vs. 46%). There were significant differences in PLT, CRP, ESR, and D-dimer between the CAL and NCA groups. ROC curve analysis showed that the sensitivities of these four indicators in diagnosing CAL were 39%, 44%, 72%, and 61%, respectively, at cut-off points of 562.5 × 109 /L, 48.93 mg/L, 45.5 mm/h, and 0.5 mg/L, respectively.

DATA CONCLUSION

The combination of NCE-CMRA and inflammatory factors is helpful for the early diagnosis and disease severity of CAL in children with KD.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Investigation of Clinical Features and Association between Vascular Endothelial Injury Markers and Cytomegalovirus Infection Associated with Thrombotic Microangiopathy in Patients with Anti-Neutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis: Case-Based Research

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) can occasionally trigger thrombotic microangiopathy (TMA). Cytomegalovirus (CMV) may be reactivated during intensive immunosuppressive therapy for AAV and cause TMA. Therefore, we aimed to evaluate the clinical features of and the association between vascular endothelial injury markers and TMA due to CMV in patients with AAV. A 61-year-old female was diagnosed with AAV and severe kidney injury. Immunosuppressive therapy gradually improved her symptoms and laboratory findings. However, 2 weeks after induction therapy initiation, she exhibited altered consciousness, a significant decrease in platelet count, and hemolytic anemia, resulting in a TMA diagnosis. Plasma exchange did not improve TMA findings and routine screening test revealed CMV infection. Ganciclovir injection improved the infection and TMA findings. Consequently, we diagnosed her with CMV-induced TMA. Both AAV and CMV may induce severe vascular endothelial injury, potentially leading to TMA development. CMV-induced TMA should be considered when TMA develops during induction therapy against AAV. Moreover, of the three serum markers of vascular injury-serum sulfatides, soluble thrombomodulin, and pentraxin 3-serum sulfatides may be associated with the development of TMA, and a high level of soluble thrombomodulin may be associated with the development of CMV viremia during the clinical course of AAV.

Arterial Stiffness as a Surrogate Marker of Cardiovascular Disease and Atherosclerosis in Patients with Vasculitides: A Literature Review

Vasculitis, a group of systemic inflammatory diseases that affect the cardiovascular (CV) system, presents with a variety of clinical manifestations that depend on the size of the affected blood vessels. While some types of vasculitis reveal distinct symptoms, others are characterized by more diffuse and nonspecific presentations that can result in delayed diagnosis and treatment initiation. Interestingly, patients with vasculitides share a significant comorbidity: an elevated CV risk, contributing to increased rates of CV events and mortality. This heightened risk is caused by cumulative inflammatory burden, traditional CV risk factors, medication effects, and reduced physical fitness. Traditional risk assessment tools, commonly used in the general population, frequently underestimate the CV risk in patients with inflammatory rheumatic conditions. Consequently, novel approaches are necessary to stratify the precise CV risk in vasculitis patients. A number of surrogate parameters for CV risk have been investigated, with arterial stiffness emerging as a promising marker. Pulse wave velocity (PWV) is a well-established method for assessing arterial stiffness and predicting CV risk across different populations. Among numerous PWV variants, carotid-femoral PWV (cfPWV) stands out as the most extensively studied and accepted reference standard. It has demonstrated its utility as a surrogate CV parameter both in the general population and in patients with systemic inflammatory rheumatic diseases. In recent years, research has expanded to assess arterial stiffness in systemic rheumatic diseases, such as arthritis, connective tissue diseases, rheumatologic overlap syndromes, and chronic pain disorders, using measurements of PWV and other markers of arterial compliance and elasticity. Despite burgeoning research in rheumatologic diseases, data on CV risk markers in vasculitides remain limited and fragmented. This narrative review aims to provide a comprehensive overview of arterial stiffness as a potential screening marker for CV diseases, atheromatosis, and ultimately CV risk among patients with vasculitides.

The dichotomy of glucocorticosteroid treatment in immune-inflammatory rheumatic diseases: an evidence-based perspective and insights from clinical practice

Objectives

Glucocorticosteroids (GCs) are the most used anti-inflammatory and immunosuppressive drugs due to their effectiveness in managing pain and disease modification in many immune-inflammatory rheumatic diseases (IRDs). However, their use is limited because of adverse effects (AEs).

Material and methods

The authors analyzed recent studies, including randomized controlled trials (RCTs), observational, translational studies and systematic reviews, providing an in-depth viewpoint on the benefits and drawbacks of GC use in rheumatology.

Results

Glucocorticosteroids are essential in managing life-threatening autoimmune diseases and a cornerstone in many IRDs given their swift onset of action, necessary in flares. Several RCTs and meta-analyses have demonstrated that when administered over a long time and on a low-dose basis, GC can slow the radiographic progression in early rheumatoid arthritis (RA) patients by at least 50%, satisfying the conventional definition of a disease-modifying anti-rheumatic drug (DMARD). In the context of RA treatment, the use of modified-release prednisone formulations at night may offer the option of respecting circadian rhythms of both inflammatory response and HPA activation, thereby enabling low-dose GC administration to mitigate nocturnal inflammation and prolonged morning fatigue and joint stiffness. Long-term GC use should be individualized based on patient characteristics and minimized due to their potential AEs. Their chronic use, especially at medium/high dosages, might cause irreversible organ damage due to the burden of metabolic systemic effects and increased risk of infections. Many international guidelines recommend tapering/withdrawal of GCs in sustained remission. Treat-to-target (T2T) strategies are critical in setting targets for disease activity and reducing/discontinuing GCs once control is achieved.

Conclusions

Glucocorticosteroids' use in treating IRDs should be judicious, focused on minimizing use, tapering and discontinuing treatment, when possible, to improve long-term safety. Glucocorticosteroids remain part of many therapeutic regimens, particularly at low doses, and elderly RA patients, especially with associated chronic comorbidities, may benefit from long-term low-dose GC treatment. A personalized GC therapy is essential for optimal long-term outcomes.

PET-Derived Increased Inflammation in Large Vessels is linked to Relapse-Free Survival in Patients with Giant Cell Arteritis

BACKGROUND

 Despite anti-inflammatory treatment, patients with giant cell arteritis (GCA) experience relapse. We aimed to determine respective relapse predictors focusing on [18F]fluorodeoxyglucose ([18F]FDG)-PET-based parameters.

MATERIAL AND METHODS

 21 therapy-naïve GCA patients received [18F]FDG-PET/CT. Patients were divided in two groups: those who relapsed during course of disease and those who did not. Median follow up was 15 months. [18F]FDG-PET/CT was analyzed for visual (PET vascular activity score [VAS]) and quantitative parameters, including Target-to-background-Ratio with liver (TBRliver) and jugular vein (TBRjv) serving as reference tissues. In addition, clinical parameters were tested.

RESULTS

 8/21 (38.1 %) had relapse. Clinical parameters could not significantly discriminate between relapse vs no-relapse, including age (p = 0.9) or blood-based inflammatory markers (white blood cell counts [WBC] and c-reactive protein [CRP], p = 0.72, each). PETVAS score could also not differentiate between respective subgroups (p = 0.59). In a quantitative assessment, TBRjv demonstrated a trend towards significance (p = 0.28). TBRliver, however, separated between patients with and without relapse (p = 0.03).

CONCLUSION

 [18F]FDG PET quantification of vessels may be useful to identify GCA patients prone to relapse during follow-up.

Design and Protocol for Beijing Hospital Takayasu Arteritis (BeTA) Biobank

BACKGROUND

Although hundreds of studies have been conducted, our understanding of the pathogenesis, indications for surgical intervention, and disease markers of Takayasu arteritis (TAK) are still limited. Collection of biological specimens, clinical data and imaging data will facilitate translational research and clinical studies. In this study, we aim to introduce the design and protocol for the Beijing Hospital Takayasu Arteritis (BeTA) Biobank.

METHODS

Based in the Department of Vascular Surgery of Beijing Hospital and Beijing Hospital Clinical Biological Sample Management Center, the BeTA Biobank is composed of clinical data and sample data from patients with TAK requiring surgical treatment. All clinical data of participants are collected, including demographic characteristics, laboratory tests, imaging results, operation information, perioperative complications, follow-up data, etc. Both blood samples including plasma, serum and cells, and vascular tissues or perivascular adipose tissue are collected and stored. These samples will promote the establishment of a multiomic database for TAK and help to identify disease markers and to explore potential targets for specific future drugs for TAK.

Case report: Rapid development of amyloid A amyloidosis in temporal arteritis with SAA1.3 allele; An unusual case of intestinal amyloidosis secondary to temporal arteritis

Temporal arteritis (TA) is a large-vessel vasculitis mostly seen in older patients. Amyloid A (AA) amyloidosis secondary to a chronic inflammation induces multiple organ dysfunctions, including a dysfunction of the gastrointestinal tract. Herein, we present a case of TA complicated by AA amyloidosis that was resistant to oral and intravenous steroids. An 80-year-old man with a history of new-onset headache, jaw claudication, and distended temporal arteries was referred to our department. On admission, the patient presented with tenderness and a subcutaneous temporal nodule in both temple arteries. Ultrasonography of the nodule revealed an anechoic perivascular halo surrounding the right temporal artery. Following the diagnosis of TA, high-dose prednisolone therapy was initiated. However, the patient presented with recurrent abdominal pain and refractory diarrhea. Due to the unclear origin of refractory diarrhea, an extensive workup, including biopsy of the duodenal mucosa, was performed. Endoscopy revealed chronic inflammation in the duodenum. Immunohistochemical analysis of duodenal mucosal biopsy samples revealed AA amyloid deposition resulting in the diagnosis of AA amyloidosis. After tocilizumab (TCZ) administration, refractory diarrhea reduced; however, the patient died of intestinal perforation 1 month after the start of TCZ administration. Gastrointestinal involvement was the main clinical manifestation of AA amyloidosis in the present case. This case highlights the importance of bowel biopsy screening for amyloid deposition in patients with unexplained gastrointestinal tract symptoms, even in a recent onset of large-vessel vasculitis. In the present case, the carriage of the SAA1.3 allele likely contributed to the rare association of AA amyloidosis with TA.

Pathogenesis of giant cell arteritis with focus on cellular populations

Giant cell arteritis (GCA), the most common non-infectious vasculitis, mainly affects elderly individuals. The disease usually affects the aorta and its main supra-aortic branches causing both general symptoms of inflammation and specific ischemic symptoms because of the limited blood flow due to arterial structural changes in the inflamed arteries. The pathogenesis of the GCA is complex and includes a dysregulated immune response that affects both the innate and the adaptive immunity. During the last two decades several studies have investigated interactions among antigen-presenting cells and lymphocytes, which contribute to the formation of the inflammatory infiltrate in the affected arteries. Toll-like receptor signaling and interactions through the VEGF-Notch-Jagged1 pathway are emerging as crucial events of the aberrant inflammatory response, facilitating among others the migration of inflammatory cells to the inflamed arteries and their interactions with the local stromal milieu. The increased use of checkpoint inhibitors in cancer immunotherapy and their immune-related adverse events has fed interest in the role of checkpoint dysfunction in GCA, and recent studies suggest a dysregulated check point system which is unable to suppress the inflammation in the previously immune-privileged arteries, leading to vasculitis. The role of B-cells is currently reevaluated because of new reports of considerable numbers of plasma cells in inflamed arteries as well as the formation of artery tertiary lymphoid organs. There is emerging evidence on previously less studied cell populations, such as the neutrophils, CD8+ T-cells, T regulatory cells and tissue residing memory cells as well as for stromal cells which were previously considered as innocent bystanders. The aim of this review is to summarize the evidence in the literature regarding the cell populations involved in the pathogenesis of GCA and especially in the context of an aged, immune system.

Systematic evaluation of imaging techniques and baseline characteristics in patients with suspected vasculitis

Purpose

To assess the diagnostic value of different imaging modalities in distinguishing systemic vasculitis from other internal and immunological diseases.

Methods

This retrospective study included 134 patients with suspected vasculitis who underwent ultrasound, magnetic resonance imaging (MRI), or ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) between 01/2010 and 01/2019, finally consisting of 70 individuals with vasculitis. The main study parameter was the confirmation of the diagnosis using one of the three different imaging modalities, with the adjudicated clinical and histopathological diagnosis as the gold standard. A secondary parameter was the morphological appearance of the vessel affected by vasculitis.

Results

Patients with systemic vasculitis had myriad clinical manifestations with joint pain as the most common symptom. We found significant correlations between different imaging findings suggestive of vasculitis and the final adjudicated clinical diagnosis. In this context, on MRI, vessel wall thickening, edema, and diameter differed significantly between vasculitis and non-vasculitis groups (p < 0.05). Ultrasound revealed different findings that may serve as red flags in identifying patients with vasculitis, such as vascular occlusion or halo sign (p = 0.02 vs. non-vasculitis group). Interestingly, comparing maximal standardized uptake values from PET/CT examinations with vessel wall thickening or vessel diameter did not result in significant differences (p > 0.05).

Conclusions

We observed significant correlations between different imaging findings suggestive of vasculitis on ultrasound or MRI and the final adjudicated diagnosis. While ultrasound and MRI were considered suitable imaging methods for detecting and discriminating typical vascular changes, ¹⁸F-FDG PET/CT requires careful timing and patient selection given its moderate diagnostic accuracy.

Neutrophil activation in patients with anti-neutrophil cytoplasmic autoantibody-associated vasculitis and large-vessel vasculitis

Objective

To assess markers of neutrophil activation such as calprotectin and N-formyl methionine (fMET) in anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) and large-vessel vasculitis (LVV).

Methods

Levels of fMET, and calprotectin, were measured in the plasma of healthy controls (n=30) and patients with AAV (granulomatosis with polyangiitis (GPA, n=123), microscopic polyangiitis (MPA, n=61)), and LVV (Takayasu’s arteritis (TAK, n=58), giant cell arteritis (GCA, n=68)), at times of remission or flare. Disease activity was assessed by physician global assessment. In vitro neutrophil activation assays were performed in the presence or absence of formyl peptide receptor 1 (FPR1) inhibitor cyclosporine H.

Results

Levels of calprotectin, and fMET were elevated in patients with vasculitis as compared to healthy individuals. Levels of fMET correlated with markers of systemic inflammation: C-reactive protein (r=0.82, p<0.0001), and erythrocyte sedimentation rate (r=0.235, p<0.0001). The neutrophil activation marker, calprotectin was not associated with disease activity. Circulating levels of fMET were associated with neutrophil activation (p<0.01) and were able to induce de novo neutrophil activation via FPR1-mediated signaling.

Conclusion

Circulating fMET appears to propagate neutrophil activation in AAV and LVV. Inhibition of fMET-mediated FPR1 signaling could be a novel therapeutic intervention for systemic vasculitides.

Large-vessel vasculitis

Large-vessel vasculitis (LVV) manifests as inflammation of the aorta and its major branches and is the most common primary vasculitis in adults. LVV comprises two distinct conditions, giant cell arteritis and Takayasu arteritis, although the phenotypic spectrum of primary LVV is complex. Non-specific symptoms often predominate and so patients with LVV present to a range of health-care providers and settings. Rapid diagnosis, specialist referral and early treatment are key to good patient outcomes. Unfortunately, disease relapse remains common and chronic vascular complications are a source of considerable morbidity. Although accurate monitoring of disease activity is challenging, progress in vascular imaging techniques and the measurement of laboratory biomarkers may facilitate better matching of treatment intensity with disease activity. Further, advances in our understanding of disease pathophysiology have paved the way for novel biologic treatments that target important mediators of disease in both giant cell arteritis and Takayasu arteritis. This work has highlighted the substantial heterogeneity present within LVV and the importance of an individualized therapeutic approach. Future work will focus on understanding the mechanisms of persisting vascular inflammation, which will inform the development of increasingly sophisticated imaging technologies. Together, these will enable better disease prognostication, limit treatment-associated adverse effects, and facilitate targeted development and use of novel therapies.

An Update on Childhood-Onset Takayasu Arteritis

Takayasu Arteritis (TAK) is a rare large vessel vasculitis affecting the aorta and its major branches. The heterogeneous and often severe clinical manifestations result from systemic and local inflammation as well as end-organ ischemia. Disease flares are common and contribute to accrued damage over time with significant morbidity and mortality. Newer understanding of the pathogenesis in TAK has paved the way for the use of pathway targeting agents such as tumor necrosis factor (TNF)α- or interleuking (IL)-6-inhibitors with improved disease control. Nevertheless, long-term data are lacking, particularly in children; prognosis often remains guarded and the disease burden high. This article aims at providing a comprehensive review of childhood-onset TAK with a focus on recent publications.

Using the co-expression network of T cell-activation-related genes to assess the disease activity in Takayasu's arteritis patients

Background

There have been lacking reliable serum biomarkers in assessing the disease activity of Takayasu’s arteritis (TAK). This study aimed to assess the disease activity of TAK by assayed gene expression levels in peripheral mononuclear cells (PBMCs).

Methods

The expression level of genes that essential in T cell activation in PBMCs in active TAK patients, inactive TAK patients, and healthy controls were detected by real-time fluorescence quantitative polymerase chain reaction, including TCR, CD28, CD40, CD40L, PD-1, PD-L1, PD-L2, CTLA4, TIGIT, TIM3, LAG3, CCL5, T-bet, RORC, and FOXP3. Gene co-expression network was established, and the signature of the topology structure in active TAK patients compared to the inactive TAK patients were extracted and described by formulas. Respectively, the disease activity was assessed by the routine serum biomarkers, including ESR, CRP, IL-6, and TNF-α, the gene expression level of TCR, CD28, T-bet, and RORC, as well as the signature of the topology structure, and the diagnostic efficacies were compared.

Results

Compared with the inactive TAK patient group, the active TAK patient group had a greater clustering coefficient in the network consisting of genes that essential in T cell activation. When assessing the disease activity used this signature of topology structure, the sensitivity was 90.9%, the specificity was 100%, and the AUC was 0.98, which was greater than the AUCs of these biomarkers.

Conclusions

The signature of the topology structure could distinguish the active TAK patients from inactive TAK patients. This maybe is a novel evaluation algorithm of disease activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02636-2.

Feasibility and usefulness of a fast-track clinic for patients suspected of polymyalgia rheumatica: notes for a work schedule through a narrative review of published literature

Objectives

Fast-track clinics (FTC) have been introduced in different fields and have been reporting significant outcomes in terms of reducing mortality, morbidity, and financial costs. To date, scarce evidence is available for FTC specific for patients suspected of polymyalgia rheumatica (PMR). The primary aim of our paper is to provide an overview of the clinical impact of PMR on patients and the healthcare system by analysing multiple aspects: the median time from onset of symptoms to diagnosis and the burden of the disease both on the healthcare system costs and on patients' quality of life (QoL). Secondarily, based on these data, we aim to discuss the potential advantages and feasibility of a PMR FTC in everyday clinical practice.

Material and methods

We performed a narrative non-systematic review (PRISMA protocol not followed) of PubMed and Medline (OVID interface) with the following MeSH terms: [polymyalgia rheumatica AND diagnosis OR diagnosis, delayed OR patient care OR early diagnosis OR length of stay OR costs OR healthcare system OR quality of life] or [polymyalgia rheumatica AND glucocorticoids AND side effects]. We decided to exclude every paper that did not report raw data in terms of diagnostic time or delay, hospitalization rate, socio-economic costs on the healthcare system, patients' QoL, and glucocorticoids-related events in PMR patients. Papers focused primarily on giant cell arteritis patients with overlapping PMR were also excluded. Abstract archives of the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) congresses of the last 10 years were screened and included in the search if raw data were available. Each paper's reference list was scanned for additional publications meeting this study's aims. When papers reported data partially presented in previous articles, we opted to use the most recently published data.

Results

According to our literature review, a PMR FTC might lighten the burden of the disease. Nevertheless, its feasibility depends mostly on the resources of the national health system and of the territorial health district, which are heterogeneously limited. The usefulness of PMR FTCs depends on closer collaboration with the general practitioner because he/she is the first clinician to visit patients with PMR.

Conclusions

Polymyalgia rheumatica fast-track clinics might lighten the burden of the disease. However, it has some limits that should carefully assessed in planning health policies.

Immune system activation in polymyalgia rheumatica: Which balance between autoinflammation and autoimmunity? A systematic review

BACKGROUND AND AIM

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease that is common in elderly people. Its classification in the spectrum of autoinflammatory and autoimmune diseases is difficult because of its only partially understood immune-mediated mechanisms. The literature concerning the innate and adaptive immune system activation in PMR was systematically reviewed highlighting the relative weight of autoinflammation and autoimmunity in its pathogenesis and disease progression.

METHODS

A literature search on PubMed Central and Embase scientific databases was performed by two independent reviewers. To be eligible, the studies needed to fully satisfy our initial PICO framework: a primary diagnosis of PMR as a population, the search for immune/inflammatory cells, cytokines and autoantibodies as an intervention, a control group consisting in healthy controls, patients with other inflammatory rheumatic diseases or PMR patients in remission after treatment and as outcomes the results of the investigations in the analyzed tissue samples. The most relevant data of the included papers were extracted by using a standardized template.

RESULTS

Of the 933 screened abstracts, 52 papers were included in the systematic review and categorized depending on their primary research objectives. The hyper-activity of neutrophils and monocytes, expressing toll-like receptor 7 in active disease, an impaired phagocytosis and endothelial dysfunction, as well as an increased count of innate T cells in patients with remission emerged among the major derangements of the innate immune response in PMR. Among the cytokines profile, interleukin-6 plays a key role but other pro-inflammatory mediators and angiogenesis markers such as chemokines, B-cell activating factor, vascular endothelial growth factor and angiopoietins seem to be involved in refractory or glucocorticoid-resistant PMR. The aberrant adaptive immune response was documented by tissue and serum findings of polarized T cells towards T helper 1 and 17 phenotypes, an increased expression of immunosenescent surface markers and a downregulated immunoregulatory response. The altered distribution of peripheral B cells, detected during active disease, suggested their peripheral migration towards unidentified sites. The interaction between innate and adaptive immune response was documented by a synovial infiltrate of macrophages and T cells. Despite multiple autoantibodies have been detected in PMR patients, none proved to correlate with disease activity seeming to be reactive to the marked inflammation or antigenic determinants provided by environmental triggers or tissue/cell damage.

CONCLUSIONS

The complex network between innate and adaptive immune system in PMR is supported by findings at molecular and cellular levels. By considering both the ends of the pathophysiological spectrum of immune-mediated rheumatic diseases, PMR may be regarded as an inflammatory immune-mediated disease with mixed mechanisms in a background of genetic and epigenetic factors together with immunological and endocrine senescence.

Functionally Heterogenous Macrophage Subsets in the Pathogenesis of Giant Cell Arteritis: Novel Targets for Disease Monitoring and Treatment

Giant cell arteritis (GCA) is a granulomatous large-vessel vasculitis that affects adults above 50 years of age. In GCA, circulating monocytes are recruited to the inflamed arteries. With cues from the vascular microenvironment, they differentiate into macrophages and play important roles in the pathogenesis of GCA via pro-inflammatory cytokine production and vascular remodeling. However, a deeper understanding of macrophage heterogeneity in GCA pathogenesis is needed to assist the development of novel diagnostic tools and targeted therapies. Here, we review the current knowledge on macrophage heterogeneity and diverse functions of macrophage subsets in the pathogenesis of GCA. We next discuss the possibility to exploit their heterogeneity as a source of novel biomarkers and as targets for nuclear imaging. Finally, we discuss novel macrophage-targeted therapies and future directions for targeting these cells in GCA.

Application progress of multiple imaging modalities in Takayasu arteritis

Takayasu arteritis (TA) is a chronic, idiopathic, granulomatous large vessel vasculitis of unknown etiology. The clinical manifestations of TA are incredibly variable, mainly depending on the location of the lesions. In the light of its insidious progress and the diversity of clinical manifestations, a substantial proportion of patients might experience a considerable delay in diagnosis, which leads to irreversible malignant complications, highlighting the importance of early diagnosis. There has been accumulating evidence that early identification of disease is pivotal to initiate timely therapy and ameliorate the prognosis. Therefore, this review discusses and summarizes the latest evidence on the application progress of multiple imaging modalities.