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Quartuccio L, Baldini C, Priori R, Bartoloni E, Carubbi F, Alunno A, Gandolfo S, Colafrancesco S, Giacomelli R, Gerli R, Valesini G, Bombardieri S, De Vita S. Cryoglobulinemia in Sjögren Syndrome: A Disease Subset that Links Higher Systemic Disease Activity, Autoimmunity, and Local B Cell Proliferation in Mucosa-associated Lymphoid Tissue. J Rheumatol 2017; 44:1179-1183. [PMID: 28507188 DOI: 10.3899/jrheum.161465] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare systemic disease activity by validated tools, i.e., the European League Against Rheumatism Sjögren Syndrome Disease Activity Index (ESSDAI) and the Clinical ESSDAI (ClinESSDAI) scores, between primary Sjögren syndrome (pSS) with positive serum cryoglobulins and pSS without serum cryoglobulins. METHODS There were 825 consecutive patients with pSS who were retrospectively evaluated. RESULTS The ESSDAI and the ClinESSDAI scores were significantly higher in cryoglobulin-positive patients (p < 0.0001, for both scores). Cryoglobulinemia was significantly associated with these domains: constitutional (p = 0.003), lymphadenopathy (p = 0.007), glandular (p = 0.0002), cutaneous (p < 0.0001), peripheral nervous system (p < 0.0001), hematological (p = 0.004), and biological (p < 0.0001). CONCLUSION Cryoglobulin-positive patients show the highest systemic activity in pSS.
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Affiliation(s)
- Luca Quartuccio
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy. .,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia.
| | - Chiara Baldini
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Roberta Priori
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Elena Bartoloni
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Francesco Carubbi
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Alessia Alunno
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Saviana Gandolfo
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Serena Colafrancesco
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Roberto Giacomelli
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Roberto Gerli
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Guido Valesini
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
| | - Stefano Bombardieri
- From the Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine; Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Rheumatology Unit, Sapienza University of Rome, Rome; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia, Perugia; Rheumatology Unit, University of L'Aquila, L'Aquila, Italy.,L. Quartuccio, MD, PhD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; C. Baldini, MD, Rheumatology Unit, Department of Internal Medicine, University of Pisa; R. Priori, MD, Rheumatology Unit, Sapienza University of Rome; E. Bartoloni, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; F. Carubbi, MD, Rheumatology Unit, University of L'Aquila; A. Alunno, MD, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; S. Gandolfo, MD, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia; S. Colafrancesco, MD, Rheumatology Unit, Sapienza University of Rome; R. Giacomelli, MD, Professor, Rheumatology Unit, University of L'Aquila; R. Gerli, MD, Professor, Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Perugia; G. Valesini, MD, Professor, Rheumatology Unit, Sapienza University of Rome; S. Bombardieri, MD, Professor, Rheumatology Unit, Department of Internal Medicine, University of Pisa; S. De Vita, MD, Professor, Rheumatology Clinic, Department of Medical and Biological Sciences, Azienda Ospedaliero-Universitaria S. Maria della Misericordia
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