Sex differences in autoimmune disease

Perinatal Use and Discontinuation of Disease-Modifying Antirheumatic Drugs: Outcomes of Patients Seen at a Pregnancy and Rheumatic Diseases Clinic

BACKGROUND

Managing rheumatic disease activity using pregnancy-compatible medications is essential for reducing adverse maternal and fetal outcomes. We characterized medication use and discontinuation before, during, and after pregnancy, among female patients with rheumatic diseases attending a targeted pregnancy and rheumatic diseases clinic.

METHODS

We conducted a cross-sectional medical record review of female patients with rheumatic diseases at a Canadian clinic between January 2017 and July 2020. Patients were categorized by pregnancy stage at their latest clinic visit: (1) preconception; (2) pregnant; (3) postpartum. We assessed use of conventional, biologic, and targeted synthetic disease-modifying antirheumatic drugs (DMARDs), prednisone, and nonsteroidal anti-inflammatory drugs across 6 perinatal windows: 24 and 12 months preconception, each pregnancy trimester, and 3 months postpartum. We reported adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for medication discontinuation in the first trimester and subsequent disease flare.

RESULTS

Of 230 included patients, 85 (37.0%), 12 (5.2%), and 133 (57.8%) were preconception, pregnant, and postpartum, respectively. Approximately half experienced at least 1 disease flare during each pregnancy stage (56.4% preconception, 58.1% during pregnancy, and 53.7% postpartum). Most used at least 1 DMARD throughout the perinatal period (82.6% preconception, 55.6% during pregnancy, and 45.1% postpartum). Overall, 25.5% discontinued at least 1 DMARD in the first trimester. DMARD discontinuation was associated with disease flare during pregnancy (aOR, 1.49; 95% CI, 0.55-4.03; p = 0.87) and postpartum (aOR, 3.09; 95% CI, 0.83-11.47; p = 0.09).

CONCLUSIONS

Patients receiving care at a pregnancy and rheumatic disease clinic show perinatal medication use patterns consistent with recent recommendations and clinical guidelines.

Health and Gender Inequalities of the COVID-19 Pandemic: Adverse Impacts on Women's Health, Wealth and Social Welfare

In this paper we discuss the nexus of health and gender inequalities associated with the COVID-19 pandemic and highlight its adverse impacts on women's health, welfare and social standing. The COVID-19 pandemic has exposed the link between socio-economic inequalities and health outcomes, especially in the area of rheumatic and musculoskeletal (RMDs) diseases. Women are more adversely affected by RMDs diseases compared to men. Epidemiological research carried out over several decades has demonstrated the presence of clear gender patterns in the manifestation of musculoskeletal diseases, including osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SS) and osteoporosis (OP). The public health measures that have been adopted to curb the spread of Sars-COV-2 are expected to have a particularly detrimental impact on women in the long term precisely because of the nexus between health outcomes and socio-economic structures. Moreover, the prioritization of urgent care will further compound this effect. COVID-19 has created a condition of ontological insecurity that is becoming increasingly manifested through various chronic diseases and associated comorbidities. RMDs and their impact on mobility and the ability of individuals to be independent, happy and mobile is a key public health challenge in the post-COVID-19 reality and a key part of the ongoing pandemic. There is an urgent need to engage with policymakers to publicize and prioritize this problem and develop viable solutions to address it.

Gene Expression of ABHD6, a Key Factor in the Endocannabinoid System, Can Be Modulated by Female Hormones in Human Immune Cells

One of the main risk factors for the development of an autoimmune disease is to be a woman. Much attention has been given to the involvement of female hormones in their etiology and sexual bias, although the mechanisms behind this potentially strong contribution in disease susceptibility are poorly understood. ABHD6 gene was recently identified as a risk factor for system lupus erythematosus and the risk was correlated with overexpression of the gene. ABHD6 is an enzyme that degrades the 2-arachidonoylglycerol, an endocannabinoid with immunomodulatory effects. Thus its degradation could contribute to immune dysregulation and development of autoimmune reactions. Sex hormones, such as estrogens, are believed to regulate important genes in the endocannabinoid pathway. However, no study was available regarding the effect of these hormones in human immune cells. In this study, ABHD6 expression was evaluated by quantitative PCR in leukocytes from healthy male and females and in the presence of estrogen or progesterone (PG). A statistical increase in ABHD6 expression could be detected in women. In the presence of estrogen or PG, a statistical upregulation of ABHD6 was observed, and in a sex-dependent manner, as only female cells responded to stimulation. Our results suggest that female hormones can promote the overexpression of ABHD6 in immune cells. This can potentially contribute to a pro-inflammatory scenario and partially explain the association of this gene in the development of LES, a highly female-biased disease.

Chronic Uveitis Following Neodymium-Doped Yttrium Aluminum Garnet Laser Peripheral Iridotomy

PURPOSE

Assessment of a chronic uveitis entity in nonuveitic patients following neodymium-doped yttrium aluminum garnet (Nd:YAG) laser peripheral iridotomy.

METHODS

A 7-year retrospective observational case series of 5 patients that developed chronic uveitis following a Nd:YAG laser peripheral iridotomy treatment.

RESULTS

Five eyes of 5 nonconsecutive patients had developed chronic anterior uveitis lasting >12 weeks. Four patients were female, with a mean age of 60.3 years (range, 48 to 83 y), and a mean follow-up duration of 8 months after initiation of treatment.

CONCLUSIONS

Chronic anterior uveitis should be addressed as a possible risk in patients undergoing Nd:YAG laser iridotomies. A larger prospective study would be necessary in establishing and exploring the association between these 2 entities.

Risk of Premenopausal and Postmenopausal Breast Cancer among Multiple Sclerosis Patients

Objective

To investigate risk of premenopausal and postmenopausal breast cancer among Multiple Sclerosis (MS) patients, considering tumor stage.

Methods

The Swedish Patient Register identified 19,330 women with MS between 1968 and 2012, matched individually with a cohort of 193,458 without MS. Matching variables were year of birth, sex, region of residence and vital status at the time of diagnosis. The cancer register identified 471 and 5,753 breast cancer cases among the MS and non-MS cohorts, respectively. Cox proportional hazard models estimated hazard ratios (HR) and 95% confidence intervals (CI) for premenopausal and postmenopausal breast cancer.

Results

Overall risk of postmenopausal breast cancer was 13% higher among MS patients compared with women without MS (HR = 1.13, 95% CI 1.02–1.26). Stratified analyses showed that the risk was statistically significantly increased in women diagnosed between 1968 and 1980 and those who were diagnosed at age 65 or older age. We observed a non-statistically significant risk only for stage 0–1 postmenopausal breast cancer (HR = 1.17, 95% CI 0.93–1.48). MS was not associated with premenopausal breast cancer.

Conclusion

The modest increased risk of postmenopausal breast cancer in women with MS may be due to surveillance bias, where contact with health services for one disease increases the risk of a second diagnosis being recorded.

BAFF Expression is Modulated by Female Hormones in Human Immune Cells

Among several autoimmune diseases, one of the main risk factors is the female gender, and much consideration has been given to the involvement of female hormones in their etiology. B-cell activating factor (BAFF) is a key factor in survival and maturation of B cells and is overexpressed in several autoimmune patients although the mechanism behind this feature is unclear. In murine models, BAFF expression could be upregulated by exogenous estrogen treatment in splenocytes; however, no evidence of this relationship was available in humans. Here, leukocytes from healthy male and female individuals were collected and cultivated in the presence or absence of estrogen or progesterone. BAFF gene expression was accessed by quantitative PCR and compared between treated and untreated group of cells. In the presence of estrogen, BAFF expression was upregulated by more than 5 times in both genders. When exposed to progesterone, the female-originated cells showed increased expression, while the cells of male origin a significant downregulation of BAFF. Our results suggest that female hormones can modulate the expression of BAFF, a key cytokine in autoimmune pathways, in human immune cells. These data might contribute to the understanding of the etiology as well as the gender bias featured by several autoimmune disorders.

Anti-AMPA-Receptor Encephalitis Presenting as a Rapid-Cycling Bipolar Disorder in a Young Woman with Turner Syndrome

Background. Autoimmune encephalitis is a disorder characterised by the subacute onset of seizures, short-term memory loss, and psychiatric and behavioural symptoms. Initially, it was recognised as a paraneoplastic disorder, but recently a subgroup of patients without systemic cancer was identified. Case Description. We describe a 20-year-old woman with Turner syndrome presenting with a treatment-resistant rapid cycling bipolar disorder with cognitive impairment. She was diagnosed with anti-AMPA-receptor encephalitis. She showed marked improvement after starting memantine and valproic acid. Conclusion. This case description emphasises the importance of timely recognition of autoimmune limbic encephalitis in patients with psychiatric manifestations and a possible predisposition to autoimmune conditions, in order to rule out malignancy and to quickly initiate treatment.

Sex-dependent regulation of cytochrome P450 family members Cyp1a1, Cyp2e1, and Cyp7b1 by methylation of DNA

Sexual differences are only partially attributable to hormones. Cultured male or female cells, even from embryos before sexual differentiation, differ in gene expression and sensitivity to toxins, and these differences persist in isolated primary cells. Male and female cells from Swiss Webster CWF mice manifest sex-distinct patterns of DNA methylation for X-ist and for cytochrome P450 (CYP; family members 1a1, 2e1m, and 7b1. Dnmt3l is differentially expressed but not differentially methylated, and Gapdh is neither differentially methylated nor expressed. CYP family genes differ in expression in whole tissue homogenates and cell cultures, with female Cyp expression 2- to 355-fold higher and Dnmt3l 12- to 32-fold higher in males. DNA methylation in the promoters of these genes is sex dimorphic; reducing methylation differences reduces to 1- to 6-fold differences in the expression of these genes. Stress or estradiol alters both methylation and gene expression. We conclude that different methylation patterns partially explain the sex-based differences in expression of CYP family members and X-ist, which potentially leads to inborn differences between males and females and their different responses to chronic and acute changes. Sex-differential methylation may have medical effects.

Neuroprotective effects of estrogens and androgens in CNS inflammation and neurodegeneration

Multiple sclerosis (MS) is a disease characterized by inflammation and demyelination. Currently, the cause of MS is unknown. Experimental autoimmune encephalomyelitis (EAE) is the most common mouse model of MS. Treatments with the sex hormones, estrogens and androgens, are capable of offering disease protection during EAE and are currently being used in clinical trials of MS. Beyond endogenous estrogens and androgens, treatments with selective estrogen receptor modulators (SERMs) for estrogen receptor alpha (ERα) and estrogen receptor beta (ERβ) are also capable of providing disease protection. This protection includes, but is not limited to, prevention of clinical disease, reduction of CNS inflammation, protection against demyelination, and protection against axonal loss. In EAE, current efforts are focused on using conditional cell specific knockouts of sex hormone receptors to identify the in vivo targets of these estrogens and androgens as well as downstream molecules responsible for disease protection.

Sex of the cell dictates its response: differential gene expression and sensitivity to cell death inducing stress in male and female cells

Sexual dimorphisms are typically attributed to the hormonal differences arising once sex differentiation has occurred. However, in some sexually dimorphic diseases that differ in frequency but not severity, the differences cannot be logically connected to the sex hormones. Therefore, we asked whether any aspect of sexual dimorphism could be attributed to chromosomal rather than hormonal differences. Cells taken from mice at d 10.5 postconception (PC) before sexual differentiation, at d 17.5 PC after the first embryonic assertion of sexual hormones, and at postnatal day 17 (puberty) were cultured and exposed to 400 microM ethanol or 20 microM camptothecin or to infection with influenza A virus (multiplicity of infection of 5). The results showed that untreated male and female cells of the same age grew at similar rates and manifested similar morphology. However, they responded differently to the applied stressors, even before the production of fetal sex hormones. Furthermore, microarray and qPCR analyses of the whole 10.5 PC embryos also revealed differences in gene expression between male and female tissues. Likewise, the exposure of cells isolated from fetuses and adolescent mice to the stressors and/or sex hormones yielded expression patterns that reflected chromosomal sex, with ethanol feminizing male cells and masculinizing female cells. We conclude that cells differ innately according to sex irrespective of their history of exposure to sex hormones. These differences may have consequences in the course of sexually dimorphic diseases and their therapy.

Familial aggregation of IgAD and autoimmunity

BACKGROUND

The prevalence of autoimmunity is thought to be increased among IgA deficient (IgAD) individuals. However, it is currently unclear if the two conditions coincide within families.

OBJECTIVE

To evaluate the prevalence of autoimmunity among IgAD individuals and their 1 degrees relatives.

MATERIAL AND METHODS

A total of 43 IgAD individuals (32 adults and 11 children) and all available 1 degrees relatives were evaluated by a physician. A family history of autoimmunity was obtained, together with physical examination and a structured questionnaire that focused on symptoms and signs suggestive of autoimmunity.

RESULTS

Eight of the 32 (25%) adult IgAD, were found to have definite autoimmunity, with organ specific- and systemic autoimmune diseases equally distributed. None of the IgAD children had autoimmunity. Among the 1 degrees relatives, 27/269 (10%) had autoimmunity, compared to an estimate of 5% in the general population (p<0.05).

CONCLUSION

Autoimmune diseases are highly prevalent in individuals with IgAD and more common in their 1 degrees relatives than expected, thus, suggesting a possible common genetic component.

Sex differences and estrogen modulation of the cellular immune response after injury

Cell-mediated immunity is extremely important for resolution of infection and for proper healing from injury. However, the cellular immune response is dysregulated following injuries such as burn and hemorrhage. Sex hormones are known to regulate immunity, and a well-documented dichotomy exists in the immune response to injury between the sexes. This disparity is caused by differences in immune cell activation, infiltration, and cytokine production during and after injury. Estrogen and testosterone can positively or negatively regulate the cellular immune response either by aiding in resolution or by compounding the morbidity and mortality. It is apparent that the hormonal dysregulation is dependent not only on the type of injury sustained but also the amount of circulating hormones. Therefore, it may be possible to design sex-specific therapies to improve immunological function and patient outcome.

PGD gender selection for non-Mendelian disorders with unequal sex incidence

Preimplantation genetic diagnosis (PGD) was originally developed for couples whose potential offspring were at risk of severe Mendelian disorders, but has since been extended to other indications. One possible use of PGD is to perform gender selection for couples whose offspring are at increased risk of disorders that do not follow Mendelian inheritance, but which are substantially more common in one sex than another (unequal sex incidence). Here, we examine the clinical and ethical issues to be considered prior to offering PGD gender selection to reduce the risk of a child being affected by a non-Mendelian condition with unequal sex incidence. Factors to be considered include: the risk that a child of either sex will be affected by the condition; the overall reduction in risk provided by gender selection and the potential harms of the procedure. Consideration should also be given to the interests of the family and the child to be born, the seriousness of the condition and the couple's procreative autonomy. To illustrate these issues we use the example of autism, a non-Mendelian disorder that is considerably more common in males than in females.

[Chronic inflammatory disorders and reproduction]

The desire of reproduction is a true challenge for the physicians in charge of patients with chronic inflammatory disorders such as rheumatoid arthritis or other connective tissue diseases. It requires: 1) the strict evaluation of the potential risks of flare of the rheumatic disease because of the pregnancy; 2) the assessment of risks on pregnancy outcome and fetus development; 3) the management of the different anti-rheumatic agents in order to maintain optimal control of disease activity and avoid any teratogenic problem. Besides this, it clearly appears that inflammatory rheumatic diseases may have an impact on patients' fertility, which may be explained by different mechanisms, physical, psychological, hormonal or immunological. Moreover, some treatments may directly affect fertility, which may justify specific managements in order to preserve gonadic functions.

Strong associations of psoriasis with antigen processing LMP and transport genes TAP differ by gender and phenotype

Psoriasis, a skin disease with autoimmune features, can be triggered and exacerbated by genetic and environmental factors. Chemicals can break tolerance to self-antigens by interfering with antigen processing and presentation; therefore, proteins involved in antigen processing may affect susceptibility. We test here whether variants of immunoproteasome subunits LMP2 and LMP7, or antigen peptide transport proteins TAP1 (transporters associated with antigen presentation) and TAP2 are associated with psoriasis. We analyzed 7 single-nucleotide polymorphisms in 321 Caucasian (German) psoriasis patients and 235 unrelated controls by time-of-flight mass spectrometry, using the Sequenom platform. We found strong associations of psoriasis with variant alleles of LMP and TAP (OR(TAP_687): 3.3, 95% CI: 1.9-5.7). Genotype effects were generally stronger for males and LMP effects were mainly seen for psoriasis arthropathica. Our results will help define behavioral or drug treatment suggestions to patients and contribute to a better understanding of the role of low molecular weight chemicals in genetic susceptibility to autoimmune diseases.