Etanercept-induced Henoch-Schönlein purpura in a patient with ankylosing spondylitis

Rituximab as possible therapy in TNF inhibitor-induced IgA vasculitis with severe renal involvement

BACKGROUND

We observe the increasing use of tumor necrosis factor (TNF) inhibitors in patients affected by chronic inflammatory diseases. These drugs provide good control of symptoms, contributing to significant improvement in the quality of life in individuals with high disease burden. On the other hand, along with their wider use and longer follow-up periods the number of reports regarding their adverse effects is also increasing. The reported complications include drug-induced vasculitis with possible kidney involvement. In the literature we can distinguish more frequently described ANCA-associated vasculitis and more rarely occurring immunoglobulin A vasculitis. Although uncommon, such complications may present with potentially life-threatening vital organ dysfunction; therefore, adequate monitoring and effective therapy are necessary.

CASE PRESENTATION

We report two cases of TNF inhibitor-induced vasculitis with severe acute worsening of renal function and significant proteinuria. The first patient was receiving golimumab therapy for ankylosing spondylitis and the second patient was treated with adalimumab for psoriasis and psoriatic arthritis. In the second case dialysis treatment was necessary and the patient presented recurrence of vasculitis after rechallenge with adalimumab. Both patients underwent renal biopsy which showed findings compatible with drug-induced IgA vasculitis and both were treated successfully with corticosteroids and rituximab.

CONCLUSIONS

To the best of our knowledge this is the first report of rituximab use in drug-induced IgA vasculitis with renal involvement. Combination of corticosteroids and rituximab can be an effective therapy in case of vasculitis with kidney failure and a preferable option for selected patients with drug-induced IgA vasculitis compared to cyclophosphamide. More studies are necessary to establish suitable short- and long-term treatment. Given the rarity of this disorder, case reports and case series can provide practical guidance until additional studies become available.

Cutaneous vasculitis associated with molecular tergeted therapies: systematic review of the literature

Cutaneo us vasculitis (CV) has a broad spectrum of etiologies, and drugs are one of the main culprits. With the increasing use of targeted therapies in medicine, especially in rheumatology and oncology, the number of CV cases reported due to these drugs has increased. Therefore, the recognition and treatment of CV associated with targeted agents have become more and more important. In the literature, anti-TNFs (n = 73, 59.5%), secukinumab (n = 7, 6%), rituximab (n = 5, 4%), tocilizumab (n = 1, 0.8%), ustekinumab (n = 8, 6.5%), abatacept (n = 3, 2.4%), Janus kinase inhibitors (n = 3, 2.4%), alemtuzumab (n = 3, 2.4%), and immune checkpoint inhibitors (n = 20, 16%) have been reported as responsible agents. However, our knowledge of the pathogenetic mechanisms is fairly limited, and the standardized management is yet to be established. Furthermore, though it is uncommon, this complication may pose a safety issue. In this manuscript, we reviewed the literature on CV with or without systemic involvement related to targeted agents. We also proposed the pathogenetic mechanisms of these adverse events. Thus, we aimed to make it easier for clinicians to manage similar cases by reviewing the diagnosis and treatment processes.

Rare case of ankylosing spondylitis complicated by IgA vasculitis

Ankylosing spondylosis (AS) is characterised by bilateral sacroiliitis, asymmetric peripheral oligoarthritis, association with the human leucocyte antigen-B27, enthesitis and dactylitis. The association of IgA vasculitis with AS has been documented in few case reports. We present a rare case of a man in his 40s with AS, who presented with fever, bloody loose stools, abdominal pain, lower limb arthritis, palpable purpura over the lower limbs. He subsequently, also developed renal involvement in the form of proteinuria. His skin biopsy showed evidence of leucocytoclastic vasculitis, while renal biopsy showed focal proliferative, necrotising IgA glomerulonephritis. He was thus diagnosed to have Henoch Schonlein purpura with IgA nephropathy in the background of AS. He was treated with steroids and mycophenolate mofetil with resolution of his symptoms.

Adjunctive treatment with infliximab in pediatric immunoglobulin A (IgA) vasculitis: A case report

Immunoglobulin A vasculitis (IgAV) is the most common childhood vasculitis affecting small vessels. No clear recommendations are available for severe pediatric cases, and until now, anti-TNF agents have had a limited role in IgAV management. In this report, we describe a pediatric case of severe IgAV, successfully treated with combined therapy including the anti-TNF, infliximab.

Biologics for immunoglobulin A vasculitis: targeting vasculitis or comorbid disease?

In this study, we aimed to evaluate the clinical features and treatments, including the use of biological disease-modifying anti-rheumatic drugs (bDMARDs) in a large cohort of pediatric and adult immunoglobulin A vasculitis (IgAV). Since data on the use of bDMARDs in IgAV are very limited, we collated the reasons for use of bDMARDs during the disease course. Patients who were enrolled in the Hacettepe University Vasculitis Research Centre (HUVAC) registry were included. In this prospective database dating from 2014, there were 436 IgAV patients classified as IgAV according to Ankara 2008 and/or American College of Rheumatology 1990 criteria. 88 adults and 330 pediatric IgAV patients were included as the main study group. Concomitant spondyloarthritis (SpA) was observed only in adult patients (10% vs 0% in children, p < 0.001). IgAV relapse was more common in adults than in children (p: 0.017). Adult patients were mostly treated with corticosteroid (p < 0.001) and conventional synthetic disease-modifying anti-rheumatic drug treatment (< 0.001), while more than half of the pediatric patients were followed up without immunosuppressive treatment. Ten (11%) adult patients used biologics. Among them, two patients used rituximab due to IgAV disease activity, three used infliximab due to SpA, three used etanercept due to SpA (one patient had a pediatric onset enthesitis-related arthritis), and two used anakinra due to recurrent familial Mediterranean fever attacks. This is the first study evaluating the use of all bDMARDs for any reason in the IgAV cohorts in the literature. None of the pediatric patients used biologics. Our data suggest biologics are mainly used for comorbid inflammatory diseases over refractory vasculitis in adult IgAV.

Protective Effect and Possible Mechanisms of Tripterygium Glycosides in Patients with Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

Objective

The safety and efficacy of Tripterygium glycosides (TG) were assessed for ankylosing spondylitis (AS) in accordance with the existing literatures.

Materials and Methods

Electronic literature was searched from Chinese VIP databases, Cochrane Library, Chinese Biomedical Literature Database, Wanfang Web of Science, EMBASE, Chinese National Knowledge Infrastructure, and the PubMed for the studies with the publication from the beginning to December 2021. Randomized controlled trials (RCTs) were included only. The major variables of result comprised erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Spinal Pain Visual Analog Score (SP-VAS), Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Moreover, the secondary variables of result covered the overall clinical effective rate following the adverse drug reaction (ADR). We carried out the meta-analysis with the use of STATA 12.0 and RevMan 5.3. We used GRADE pro3.6.1 software to assess the quality of evidence.

Results

In general, we covered 15 randomized controlled trials with the focus of 1186 patients. As proven by our meta-analysis, TG as adjuvant therapy or monotherapy decreased the BASDAI, BASFI, SP-VAS, serum CRP, and ESR than control in patients suffering from AS. Additionally, TG treatment visibly improved the overall effective rate in AS. Nevertheless, TG was not found to significantly increase the rate of ADR in contrast to the control.

Conclusion

As indicated by our result, TG may be an option to treat AS. In this paper, we recommended strict trials with high quality and large samples sizes for confirming the finding here.

Vasculitis induced by biological agents used in rheumatology practice: A systematic review

Objectives: Biological medications have been used with an increasing frequency to treat rheumatological diseases. Autoimmune events can be induced by these drugs, such as psoriasiform lesions, alopecia, lupus and, vasculitis, which more often affects the skin (small-sized vessels) and eventually other organs. In this review, we describe the clinical profile of patients with vasculitis induced by the main biological agents used in rheumatology.

Patients and methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The PubMed database was used for searching eligible articles. We included case reports, case series, and letter to the editor of patients on anti-tumor necrosis factor-alpha (anti-TNF-a) molecules, as well as tocilizumab, ustekinumab, secukinumab, rituximab, and abatacept, who had vasculitis induced by these agents.

Results: Eighty-one articles were included for final analysis (n=89). Twenty-seven patients were using infliximab, 20 adalimumab, 18 etanercept, seven secukinumab, four certolizumab, four rituximab, three golimumab, three ustekinumab, two abatacept, and one tocilizumab. Unspecific leukocytoclastic vasculitis (LCV) was the most common type of vasculitis (n=37), followed by anti-neutrophil cytoplasmic antibody (ANCA)- associated vasculitis (n=16). The medication was replaced with another biological molecule in 23 cases, with only four relapses. In six cases, the biological was maintained, but vasculitis worsened/persisted in one case, being necessary drug removal.

Conclusion: Infections, infusion reaction, cancer, and autoimmune events are well-known side effects of biological therapy. This review demonstrates that vasculitis is another adverse effect of this type of therapy, particularly the anti-TNF-a molecules, and LCV the most reported type of vasculitis.

Relationship Between IL1 Gene Polymorphism and Susceptibility to Ankylosing Spondylitis: An Updated and Supplemented Meta-Analysis

The literature has provided inconsistent findings on the relationship between interleukin IL-1 gene polymorphisms and susceptibility to ankylosing spondylitis (AS). Therefore, a systematic review and meta-analysis were conducted. Online electronic database searches were performed for relevant research published as of May 2021. Meta-analysis was performed to compare alleles and multiple genetic models (including dominant, recessive, heterozygous, and homozygous models) using random-effects models to reduce the impact of heterogeneity. A 95% confidence interval (95% CI) odds ratio (OR) was used to assess potential relationships. Nineteen studies including 6235 patients with AS and 5919 healthy controls were recruited. IL-1A-889 (rs1800587) had statistical significance in the allelic model (OR 1.38, 95% CI 1.08-1.77, P = 0.010) (I² = 51%.1, P = 0.0001); homozygous model (OR 1.92, 95% CI 1.27-2.89, P = 0.002); heterozygous model (OR 1.49, 95% CI 1.02-2.17, P = 0.163); dominant genetic model (OR 1.53, 95% CI 1.05-2.24, P = 0.026); and recessive model (OR 1.54, 95% CI 1.04-2.28, P = 0.031). Further stratified analysis showed that the allele model (OR 1.35, 95% CI 1.08-1.69, P = 0.008), heterozygous model (OR 1.45, 95% CI 1.07-1.96, P = 0.017), and dominant model (OR 1.49, 95% CI 1.11-1.99, P = 0.007) in the English population and allele model (OR 2.21, 95% CI 1.45-3.37, P = 0.0001), homozygous model (OR 3.85, 95% CI 1.38-10.76, P = 0.010), heterozygous model (OR 3.42, 95% CI 1.85-6.32, P = 0.0001), and dominant model (OR 3.49, 95% CI 1.93-6.30, P = 0.001) in Tunis were significantly associated with susceptibility to AS. Analysis of the IL1F7 exon 2 (rs3811047) showed that the G allele frequency was higher in the normal population than in the AS population (OR 0.76, 95% CI (0.64, 0.91)). Further stratified analysis concluded that the allele model was significantly associated with AS susceptibility in Canadian (OR 0.76, 95% CI 0.61-0.94, P = 0.011) and Chinese patients (OR 0.64, 95% CI 0.41-0.98, P = 0.041). The meta-analysis showed that the IL-1 gene polymorphism IL-1A-889 (rs1800587) increases the risk of AS in English and Tunisian populations. IL1F7 exon 2 (rs3811047) is negatively correlated with susceptibility to AS in Canadian and Chinese populations, but additional studies are needed for further exploration.

Etanercept-Induced Anti-Glomerular Basement Membrane Disease

Anti-glomerular basement membrane (anti-GBM) disease is a rare form of small-vessel vasculitis that typically causes rapidly progressive glomerulonephritis with or without alveolar haemorrhage. Previously, there has only been one reported case of tumour necrosis factor-α (TNF-α) antagonist-induced anti-GBM disease. Here, we describe the first reported case of etanercept-induced anti-GBM disease. A 55-year-old Caucasian man was referred to our tertiary specialist renal centre with a history of painless macroscopic haematuria. The patient has been receiving weekly etanercept injections over the past 12 months for psoriatic arthropathy. The serum immunology panel results highlighted a significantly raised anti-GBM titre (370.1 U). Etanercept was stopped, and the patient was empirically commenced on pulsed methylprednisolone, cyclophosphamide, and plasma exchange. A renal biopsy showed crescentic glomerulonephritis. Few days after admission, he tested positive for coronavirus disease 2019 (COVID-19), and a decision was made to withhold cyclophosphamide. There was further decline in renal function with hyperkalaemia for which he received 2 sessions of haemodialysis. He was restarted on cyclophosphamide upon discharge. The patient was switched to rituximab treatment afterwards as he developed leucopenia 2 weeks following the commencement of cyclophosphamide. The serum creatinine level continued to improve and remained dialysis-independent. In conclusion, with the increased use of etanercept and other TNF-α antagonists, the prescribing clinician must be aware of the rare but life-threatening drug-induced vasculitis. We recommend careful monitoring of renal indices with the use of this class of medications.

Glomerulonephritis in Two Patients with SpA Treated with TNF-α Blockers and a Review of the Literature

Renal failure or acute/chronic kidney damage may present as a clinical manifestation of rheumatic diseases. In addition treatment with DMARDs or biologic drugs may induce nephrotoxicity. In this case-based review, we present two patients with SpA under anti-TNF-α treatment admitted to our hospital because of renal failure and proteinuria. We review previously published yet isolated cases of TNF-α blocker-induced glomerular disease in patients with SpA. Renal manifestations are occasionally seen in patients with ankylosing spondylitis and psoriatic arthritis with IgA nephropathy being the most common of them. Anti-TNF-α agents although reportedly used for the treatment of glomerular nephropathy as a disease manifestation, they have been considered responsible for provoking renal damage in some cases. A diagnostic approach for patients with SpA treated with anti-TNF-α agents presenting with renal manifestations is proposed herein.

Intermittent Purpura Development Associated with Leukocytoclastic Vasculitis Induced by Infliximab for Crohn's Disease

Anti-tumor necrosis factor (TNF) α agents, widely used for the treatment of Crohn's disease (CD), can sometimes induce skin-associated adverse events, which mainly include psoriasis-like eruptions, eczema, and cutaneous infections. In contrast, purpura caused by vasculitis is rarely seen. We herein report a unique case of leukocytoclastic vasculitis induced by infliximab administered for CD in which intermittent purpura development was noted. Fluorescent immunostaining showed no immunoglobulin A deposition on the vessel walls. No purpura was initially seen after starting infliximab, but it appeared approximately 10 months later; however, administration did not have to be discontinued, and the condition was later resolved. The present findings provide important details regarding vasculitis induced by anti-tumor necrosis factor-α agent administration.

Severe Attack of Henoch-Schönlein Purpura With Neurological Involvement During Adalimumab Treatment for Crohn's Disease

Tumour necrosis factor-α [TNF-α] inhibitors have revolutionised the management of chronic inflammatory conditions. A number of cutaneous adverse events have been reported with TNF inhibition, including vasculitis. Most reactions are mild and rarely warrant treatment withdrawal. Here we describe a patient with Crohn's disease treated with adalimumab in whom severe multivisceral Henoch-Schönlein purpura developed, including neurological involvement, requiring definitive TNF blocker withdrawal.

Associations of the IL-1B level, IL-1A and IL-1B gene polymorphisms and ankylosing spondylitis risk in a Chinese Han population

INTRODUCTION

The aim of this study was to investigate the effect of interleukin (IL)-1A and IL-1B gene polymorphisms on ankylosing spondylitis (AS) susceptibility in a Chinese population. Additionally, we examined the association of IL-1B level with different genotype of rs2853550 polymorphism and clinicopathological features of AS patients.

MATERIALS AND METHODS

The IL-1B concentration in plasma was determined by an enzyme-linked immunosorbent assay. The IL-1A rs3783546, IL-1A rs3783550 and IL-1B rs2853550 gene polymorphisms were determined by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

RESULTS

Our data indicated that the average plasma IL-1B concentration in the AS patients was markedly higher than in the control samples. Subgroup analyses suggested that there was no significant association between plasma IL-1B concentration and sex, age, HLA-B27, C-reactive protein (CRP), or grade of the sacroiliac joint in AS patients. We also found that the IL-1B rs2853550 AG genotype showed significantly correlation with an increased risk of AS. In comparing AS patients to control participants, elevated plasma concentrations were observed in AS patients while significant differences were found between the IL-1B rs2853550 AA genotypes. There is a negative correlation between the IL-1A rs3783550 and IL-1A rs3783546 polymorphisms in the AS patients in relation to controls.

CONCLUSIONS

The IL-1B concentration in plasma was markedly higher in cases and AA genotype carriers. Furthermore, IL-1B rs2853550 AG was a genetic contributor to AS risk in a Chinese population.

Henoch-Schonlein purpura associated with HLA-B27 positive axial spondyloarthritis in a young man

Axial spondyloarthropathies are characterised by bilateral sacroiliitis, asymmetric oligoarthritis, association with the human leucocyte antigen (HLA)-B27, enthesitis and dactylitis. Although IgA nephropathy has a well-documented association with seronegative spondyloarthropathies, the association with Henoch-Schonlein purpura (HSP) has been documented only in few case reports. The present case is that of a 26-year-old man who presented with fever, lower limb arthritis, abdominal pain, palpable purpura over the buttocks and lower limbs, and clinical features of sacroiliitis. His blood tests showed elevated inflammatory markers and rheumatoid factor was negative. CT scan of the sacroiliac joints confirmed sacroiliitis. Skin biopsy revealed neutrophilic small vessel vasculitis. HLA-B27 was positive in blood. A diagnosis of HSP with HLA-B27 positive axial spondyloarthritis was made. HSP can be associated with HLA-B27 positive axial spondyloarthritis and has to be considered while evaluating for causes of cutaneous small vessel vasculitis in such patients.

Associations of the VEGF level, VEGF rs2010963 G/C gene polymorphism and ankylosing spondylitis risk in a Chinese Han population

To investigate the roles of the plasma vascular endothelial growth factor (VEGF) level and VEGF gene polymorphisms in ankylosing spondylitis (AS) susceptibility. The plasma VEGF level was measured using an enzyme-linked immunosorbent assay. The VEGF rs2010963 G/C gene polymorphism was analyzed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Our data indicated that the average plasma VEGF concentration in the AS patients was markedly higher than in the controls. Stratification analysis indicated a significant correlation between an elevated plasma VEGF level in AS patients and sex, but not age, HLA-B27, C-reactive protein (CRP), or grade of the sacroiliac joint. We also found that VEGF rs2010963 G/C was associated with a decreased risk of AS. Significant differences were found between the VEGF rs2010963 G/C genotypes and elevated plasma level in AS patients when compared with the controls. However, we did not find a significant association between the plasma VEGF level and different rs2010963 G/C genotypes in the AS patients or controls. To sum up, serum VEGF levels are significantly associated with the inflammatory process of AS. This study suggests that VEGF is involved in the immunological or inflammatory process of AS.

The interaction between circulating complement proteins and cutaneous microvascular endothelial cells in the development of childhood Henoch-Schönlein Purpura

Objective

In addition to IgA, the deposition of complement (C)3 in dermal vessels is commonly found in Henoch-Schönlein purpura (HSP). The aim of this study is to elucidate the role of circulating complement proteins in the pathogenesis of childhood HSP.

Methods

Plasma levels of C3a, C4a, C5a, and Bb in 30 HSP patients and 30 healthy controls were detected by enzyme-linked immunosorbent assay (ELISA). The expression of C3a receptor (C3aR), C5a receptor (CD88), E-selectin, intercellular adhesion molecule 1 (ICAM-1), C3, C5, interleukin (IL)-8, monocyte chemotactic protein (MCP)-1, and RANTES by human dermal microvascular endothelial cells (HMVEC-d) was evaluated either by flow cytometry or by ELISA.

Results

At the acute stage, HSP patients had higher plasma levels of C3a (359.5 ± 115.3 vs. 183.3 ± 94.1 ng/ml, p < 0.0001), C5a (181.4 ± 86.1 vs. 33.7 ± 26.3 ng/ml, p < 0.0001), and Bb (3.7 ± 2.6 vs. 1.0 ± 0.6 μg/ml, p < 0.0001), but not C4a than healthy controls. Although HSP patient-derived acute phase plasma did not alter the presentation of C3aR and CD88 on HMVEC-d, it enhanced the production of endothelial C3 and C5. Moreover, C5a was shown in vitro to up-regulate the expression of IL-8, MCP-1, E-selectin, and ICAM-1 by HMVEC-d with a dose-dependent manner.

Conclusion

In HSP, the activation of the complement system in part through the alternative pathway may have resulted in increased plasma levels of C3a and C5a, which, especially C5a, may play a role in the disease pathogenesis by activating endothelium of cutaneous small vessels.

Beneficial effects of tripterygium glycosides tablet on biomarkers in patients with ankylosing spondylitis

The aim of the current study was to explore the effects and possible mechanisms of tripterygium glycosides tablet (TGT) in the treatment of active ankylosing spondylitis (AS). Thirty-six patients with active AS were given a 20 mg TGT treatment three times per day for 12 weeks, and 21 unrelated healthy controls were recruited as the control group. Efficacy measures included the Bath AS disease activity index (BASDAI), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior and subsequent to TGT treatment. Serum dickkopf homolog 1 (DKK1) and interleukin-17 (IL-17) levels before and after TGT treatment were assessed using reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and ELISA assay. The levels of several serum biomarkers were determined by ELISA, including receptor activator of nuclear factor κ-B ligand (RANKL), osteoprotegerin (OPG), bone alkaline phosphatase (BAP), bone morphogenetic protein-2 (BMP-2), matrix metalloproteinase-3 (MMP-3), cross-linked telopeptide of type II collagen (CTX-II), vascular endothelial growth factor (VEGF), and prostaglandin E2 (PGE2). After 12 weeks of TGT treatment, the BASDAI score of the patients was significantly reduced (P<0.05), their levels of ESR and CRP were significantly reduced to a normal level (P<0.05, P<0.05), RT-PCR and ELISA showed a significant increase in the level of DKK1 expression (P<0.05) and a significant decreased IL-17 expression (P<0.05), there was a significant increase in the expression of OPG, BAP and BMP-2 (P<0.01, P<0.01, P<0.01) and a significant reduction in the expression levels of RANKL, CTX-II. MMP-3, PGE2, and VEGF (P<0.01, P<0.01, P<0.01, P<0.05, P<0.01) compared with those of the controls. TGT is effective at improving the signs and symptoms of patients with AS through the regulation of serum biomarkers, and the mechanisms may be associated with the anti-inflammatory effect, inhibition of new bone formation and potential bone-protective effects.

Biologics-induced autoimmune renal disorders in chronic inflammatory rheumatic diseases: systematic literature review and analysis of a monocentric cohort

The use of biologic drugs has been linked with the paradoxical development of systemic and organ specific autoimmune processes. The aim of this study was to describe the features of biologics-induced autoimmune renal disorders (AIRD) through a systematic review and a cohort study of 707 adult patients affected with Rheumatoid Arthritis (RA), Ankylosing Spondylitis (SA) and Psoriatic Arthritis (PsA). The literature search identified 2687 articles of which 21 were considered relevant for the present study, accounting for 26 case reports. The cohort analysis retrieved 3 cases. According to clinical manifestations and kidney histology the identified AIRD cases were classified as: a) glomerulonephritis associated with systemic vasculitis (GNSV), b) glomerulonephritis in lupus-like syndrome (GNLS), c) isolated autoimmune renal disorders (IARD). Twenty-two out of 29 cases with AIRD were reported in patients affected by RA, 5 in AS and 2 in PsA. The biologic drug most frequently associated with development of AIRD was Etanercept (15 cases, 51.7%), followed by Adalimumab (9 cases, 31.0%) and Infliximab (3 cases, 10.3%) while Tocilizumab and Abatacept were reported in 1 case (3.4%) for each. Thirteen out of 29 (44.8%) cases were classified as affected by IARD, 12 (41.3%) as GNSV and 4 (13.9%) as GNLS. Worse prognosis was associated with GNSV and lack of biologic withdrawal. Although rare, AIRD may be life-threatening and may lead to renal failure and death. If AIRD occurs, biologic drugs must be stopped and patient should be treated according to clinical manifestations and kidney biopsy findings.

Effects of Tripterygium glycosides on interleukin-17 and CD4+CD25+CD127low regulatory T-cell expression in the peripheral blood of patients with ankylosing spondylitis

The aim of this study was to investigate the possible mechanisms of action of Tripterygium glycosides (TG) in the treatment of ankylosing spondylitis (AS). In total, 20 patients with active AS received treatment with 20 mg TG tablet (TGT) 3 times per day for 6 weeks. In addition, 20 healthy age- and gender-matched individuals were recruited as the control group. The efficacy measures included the Bath AS disease activity index (BASDAI), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. The serum interleukin (IL)-17 levels were measured using ELISA. The expression of CD4⁺CD25⁺CD127^low regulatory T cells (Tregs) in the peripheral blood was evaluated by flow cytometry. A bivariate correlation analysis was used to determine the association of IL-17 levels with BASDAI, ESR, CRP and CD4⁺CD25⁺CD127^low Tregs in AS patients. Prior to treatment, the BASDAI, ESR and CRP levels in AS patients were found to be elevated compared to those in healthy controls and were significantly reduced following TGT treatment (P<0.05, P<0.05 and P<0.05, respectively). Prior to treatment, the AS patients exhibited significantly higher IL-17 levels compared to those in healthy controls (P<0.05). Following TGT treatment, the IL-17 levels were significantly reduced in AS patients (P<0.01) but were not significantly different in the control subjects (P>0.05). In addition, prior to treatment, the ratio of CD4⁺CD25⁺CD127^low Tregs in AS patients was significantly lower compared to that in healthy controls (P<0.05) and it was significantly increased following TGT treatment (P<0.05). The correlation analysis between the BASDAI, ESR or CRP levels and IL-17 revealed a positive linear correlation (P<0.001, P<0.001 and P<0.01, respectively), whereas CD4⁺CD25⁺CD127^low Tregs were found to be negatively correlated with IL-17 (P<0.01). In conclusion, TGT is efficient for the treatment of AS patients and its mechanism of action may be correlated with the upregulation of CD4⁺CD25⁺CD127^low Tregs and the downregulation of IL-17 in the peripheral blood.