POS0448 SYNOVIAL TRANSCRIPTOMIC PROFILES CORRELATE WITH DISEASE ACTIVITY IN EARLY UNTREATED RHEUMATOID ARTHRITIS

Background

Synovitis is the common feature across all individuals with a diagnosis of rheumatoid arthritis (RA). Yet, cellular and transcriptomic alterations occuring in RA synovium are highly variable amongst patients. So far, most data on clinical-tissue correlations either rely on hypothesis-driven approaches or are potentially biased by heterogeneous clinical characteristics (e.g. disease duration or disease-modifying antirheumatic drugs).

Objectives

We used transcriptomic profiling of synovial tissue from early, untreated rheumatoid arthritis patients (ERA) to 1/ identify the genes with the most variable expression amongst patients and 2/ explore the ability of unbiased (data-driven) approaches to define clinically relevant ERA subgroups.

Methods

Synovial biopsies were harvested from clinically involved joints of ERA patients using needle arthroscopy or ultrasound-guided biopsy. Data on disease activity were collected at inclusion. For each sample, 350ng total RNA was sent for RNAsequencing using a standardized protocol (Macrogen Europe). After quality control (Fast QC) and genome alignement (HiSat2), normalized read counts were analyzed on Qlucore Omics Explorer. To focus on inter-sample heterogeneity, genes were filtered based on variance (σ/σmax). Unbiased approaches (Principal Component Analysis, Unsupervised Clustering) were applied to define patients’ clusters. Pathway enrichment analysis were performed on Metascape. CibersortX was used to extrapolate the immune cell subsets relative composition from gene expression data. All other statistical analyses were performed on GraphPad Prism v9.

Results

Total RNA was obtained from synovial biopsies from 74 patients. We first applied variance filtering to identify the genes whose expression showed the greatest variation between patients (n = 894 most variable genes). PCA analysis on the level of expression of these genes did not divide samples into distinct groups, instead yielding a continuous distribution broadly associated with baseline disease activity, as measured by DAS28CRP. Consequently, we used unsupervised clustering to allow for unbiased definition of two patient clusters (PtC): PtC1 (n=52) and PtC2 (n=22) based on their expression of these 894 genes. Pathway analysis of these genes revealed significant enrichment of immune system genes, in the Inflammatory response and Rheumatoid Arthritis pathways (gene cluster 1: GC1), B cell & plasma cell-related pathways (GC2) and metabolic processes-related genes (GC3). Interestingly, PtC1 and PtC2 were characterized by very different clinical features. More specifically, patients from the group with a strong B & plasma cell signature (PtC1) displayed higher baseline indices of all disease activity score components (median DAS28CRP: 5.56 vs 4.09; p-value = 0.0003). They also had higher rates of baseline radiological erosions (erosive disease in 34.6 % vs 10%; p-value = 0.0252) but similar rates of seropositive disease. In line with our pathway analyses, we found a higher signature (inferred relative frequency) of B & plasma cells, T cells and M1-like macrophages in PtC1 compared to PtC2 synovia. PtC2 synovia instead had relatively higher M2-like macrophage and resting mast cell signatures.

Conclusion

In this large synovial biopsy study, we found that synovial transcriptomic profiles in ERA patients distribute continuously based on the expression of inflammatory and immune cell transcriptomic pathways. These synovial transcriptomic signatures correlate strongly with systemic disease activity.

Acknowledgements

This work was funded in part by unrestricted grants from Cap48 (RTBF), the Fonds de la Recherche Scientifique (FNRS), and the Fund for Scientific Research in Rheumatology (FWRO/FRSR), managed by the King Baudouin Foundation. CT is funded by the FNRS and Fondation Saint-Luc (Cliniques Universitaires Saint-Luc). NL is a chercheur qualifiée of the FNRS.

Disclosure of Interests

Clément Triaille: None declared, Tatiana Sokolova: None declared, Stéphanie de Montjoye: None declared, Adrien Nzeusseu Toukap: None declared, Laurent Meric de Bellefon: None declared, Axelle Loriot: None declared, Bernard Lauwerys Shareholder of: BL owns shares (<15000€) in DNALytics, Employee of: BL is currently employed at UCB Biopharma, Patrick Durez: None declared, Nisha Limaye: None declared.

POS1091 LESS RADIOGRAPHIC SPINAL DAMAGE IN PSORIATIC ARTHRITIS PATIENTS COMPARED TO SpA PATIENTS

Background

Psoriatic arthritis (PsA) is an inflammatory joint disease that is traditionally included in the Spondyloarthritis (SpA) spectrum. Prevalence and impact of axial involvement in PsA remain understudied but increasingly affect treatment decisions.

Objectives

A step towards fathoming this issue is to report on baseline radiographic spinal damage in PsA and SpA patients (pts) from 2 prospective multicentre cohort studies in private and academic rheumatology practices.

Methods

Data on PsA pts were from the Belgian Epidemiological Psoriatic Arthritis Study (BEPAS); prospective multicentre cohort in 17 Belgian rheumatology practices. Recruitment was Dec2012-Jul2014. Pts were included when fulfilling the Classification criteria for Psoriatic Arthritis (CASPAR). SpA pts were from a Belgian observational cohort (Be-Giant) of SpA pts fulfilling the ASAS SpA classification criteria. Radiographs of the spine were obtained at baseline and after 2 years. Two calibrated readers evaluated radiographic damage by assessing modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). Readers were blinded for time sequence, clinical data and information from other obtained images (radiographs of hands, feet, sacroiliac joints). Consensus scores are described.

Results

In total 461 pts were included in BEPAS. Mean age was 52.79±12.29 years and 43.0% (n=198) were female; average disease duration was 8.5 ± 9.3 years and approximately 34% of the pts reported inflammatory axial pain. From 312 pts spinal radiographs were obtained. At baseline, the vast majority of PsA pts had an mSASSS of 0 (n=273, 87.5%), according to both readers. In 33 PsA pts (10.6%) mSASSS was 2 or more. For the SpA pts percentages were lower but the trend was similar (see Figure 1). Though lesser pts showed abnormalities, the SpA pts with spinal damage show a higher mSASSS, therefore indicating more spinal damage then the PsA pts (p<0.05). Both patient groups show some outliers with high mSASSS, increasing the average mSASSS especially in the SpA cohort (mean mSASSS = 9.1±14.11) compared to the median of 3 (IQR 2-6) in both cohorts

Syndesmophytes are seen in 10.6% and 6.2% of the PsA and SpA pts, respectively. Similar to the mSASSS, SpA pts had more syndesmophytes (mean: 4.4±5.50) compared to PsA pts (mean 2.0±1.45); p<0.05. PsA pts had more often syndesmophytes located in the cervical spine (24/35, 68.6%) compared to the SpA patient group (9/21, 42.9%); p<0.05.

Erosions and especially sclerosis and squaring are uncommon in both patient groups.

Conclusion

Spinal damage is seen in approximately 10% or less of both PsA and SpA pts in these cohorts. SpA pts show higher mSASSS values and more syndesmophytes as compared to the PsA pts. Syndesmophytes in PsA pts are more often located in the cervical spine while the location is more equally distributed in SpA pts.

Table 1.

Spinal damage at baseline of patients from the BEPAS (PsA patients) and Be-Giant (SpA patients) cohorts

PsA patients (n=312)SpA patients (n=260)PsA patients (n=312)SpA patients (n=260)mSASSS ≥2, no of patients33 (10.6%)19 (7.3%)Syndesmophytes (total spine)33 (10.6%)16 (6.2%)mSASSS ≥1, no of patients39 (12.5%)22 (8.5%)mean, (SD)2.0 (1.45)4.4 (5.50)mean, (SD)4.5 (4.24)9.1 (14.11)min, 0.25, median, 0.75, max1.0 1.0 2.0 2.0 8.01.0 1.0 2.5 5.0 22.0min, 0.25, median, 0.75, max1.0 2.0 3.0 6.0 21.01.0 2.0 3.0 10.0 64.0Syndesmophytes (cervical spine)24 (7.7%)9 (3.5%)Erosions ≥1, no of patients13 (4.2%)5 (1.9%)mean, (SD)1.8 (1.32)2.9 (2.89)mean, (SD)1.5 (1.39)1 (0.0)min, 0.25, median, 0.75, max1.0 1.0 1.0 2.0 7.01.0 1.0 2. 0 3.0 10.0min, 0.25, median, 0.75, max1.0 1.0 1.0 1.0 6.01.0 1.0 1.0 1.0 1.0Syndesmophytes (lumbar spine)11 (3.5%)12 (4.6%)Squaring ≥1, no of patientsNo obs.4 (1.5%)mean, (SD)1.9 (0.70)3.7 (4.21)mean, (SD)No obs1.8 (0.96)min, 0.25, median, 0.75, max1.0 1.0 2.0 2.0 3.01.0 1.0 1.0 5.0 12.0min, 0.25, median, 0.75, maxNo obs1.0 1.0 1.5 2.5 3.0Sclerosis ≥1, no of patients2 (0.6%)6 (2.3%)mean, (SD)1.5 (0.71)1.8 (1.33)min, 0.25, median, 0.75, max1.0 1.0 1.5 2.0 2.01.0 1.0 1.0 3.0 4.0

Acknowledgements

The BEPAS study has been supported by MSD Belgium, with noteworthy mentioning of Hermine Leroi.

Disclosure of Interests

None declared

POS0259 ULTRASOUND AS AN IMAGING BIOMARKER OF EARLY RESPONSE TO TOCILIZUMAB AND METHOTREXATE IN VERY EARLY RHEUMATOID ARTHRITIS, TOVERA – A LONGITUDINAL STUDY

Background:

The combination of methotrexate (MTX) and tocilizumab (TCZ) has been proven to be superior to MTX alone in early rheumatoid arthritis (RA)1 and was able to prevent radiographic progression. Ultrasound (US) has become a valid imaging modality in managing RA. Together with clinical examination, US may allow a comprehensive monitoring of response to therapy. So far, few data are available concerning the early response to TCZ plus MTX in very early RA (VERA).

Objectives:

In this study we aimed to assess the early US response to TCZ plus MTX in VERA, DMARD-naïve patients.

Methods:

In this open-label, single-arm study, VERA patients received TCZ (162 mg/week, subcutaneously) and MTX (15-20 mg/week, per os) for 24 weeks as induction therapy, followed by MTX as maintenance therapy. RA was diagnosed according to the 2010 ACR/European league against rheumatism (EULAR) criteria. All patients who fulfilled the inclusion criteria (ClinicalTrials.gov: NCT02837146) underwent blood tests, clinical and ultrasound examinations at the predefined time-points: 0,2,4,8,12,24,32,48,54 weeks (w). Ultrasound examination of 34 joints (elbows, wrists, MCP [1-5, bilateral], PIP ([2-5, bilateral], knees, ankles and MTP [2-5, bilateral]) was performed blindly to clinical data. Gray-scale (GS), power-Doppler (PD) scores, and the global OMERACT-EULAR synovitis score (GLOESS) were assessed in each joint. The sum of individual scores was calculated for 17-joint score (JS) (whole joint set), 10-JS (wrists, MCP, ankles and MTP joints), 12-JS2, and 7-JS3.

Results:

Forty-four patients (77% women), aged 46.7 ± 12.4 years, completed the 24-week period. Two-thirds (72.7%) were positive for anti-citrullinated protein antibody (ACPA) and 18.2% had bone erosions. At baseline, the mean 28 swollen joints count (28-SJC) was 7.55± 4.5, mean disease activity score (DAS28)-CRP score was 5.2 ± 0.15, mean simplified clinical activity score (SDAI) was 31.4 ± 1.9, mean clinical activity score (CDAI) was 29.1 ± 1.8 and mean health assessments questionnaire (HAQ) score was 1.3 ± 0.1. The C-reactive protein (CRP) decreased significantly at 2w (p<0.05) and, accordingly DAS28-CRP score decreased significantly at 4w (p<0.05). The 28-SJC and CDAI scores decreased significantly at 8w (p<0.05). The HAQ and visual analogue scale (VAS) disease activity reported by patients decreased significantly at 8w (p<0.05) and VAS fatigue at 12w (p<0.05).

The GLOESS and GS scores allowed us detecting the earliest significant treatment response at 2w and PD scores at 4w (p<0.05). Among US joint subsets, 17-JS (p<0.01), 12-JS (p<0.05) and 10-JS (p<0.05) were able to detect the earliest treatment response at 2w. The 7-joint score detected the earliest response at 4w, both in GS and PD (p<0.05).

Conclusion:

US scores were able to detect therapeutic response to TCZ plus MTX earlier than clinical scores and may therefore be a promising imaging biomarker.

References:

[1]Burmester GR et al. Ann Rheum Dis 2017; 76; 1279-1284.

[2]Naredo E et al. Arthritis Rheum 2008; 59(4): 515-522.

[3]Backhaus M et al. Arthritis Rheum 2009; 61: 1194-1201.

Disclosure of Interests:

Maria Stoenoiu Grant/research support from: UCB, Roche, Abbvie, MSD, Sanofi, Celgene, Mihaela Maruseac: None declared, Mouna Messaoudi: None declared, Adrien Nzeusseu Toukap Grant/research support from: AbbVie, Eli Lilly, Janssen, UCB, Novartis, Celgene Corporation, Pfizer, Esperanza Naredo Grant/research support from: AbbVie, Roche, BMS, Pfizer, UCB, Eli Lilly, Novartis, Janssen, Celgene

OP0119 SHOULD WE USE BIODMARDS IN FIRST INTENTION IN EARLY RHEUMATOID ARTHRITIS?: RESULTS AT 5 YEARS FROM THE ERA LOUVAIN BRUSSELS COHORT

Background:

Early effective treatment has led to major improvements in patients with rheumatoid arthritis (ERA). Low disease activity and remission are achieved earlier and in higher frequency when the initial treatment in rheumatoid arthritis includes a combination of methotrexate (MTX) with a bDMARD compared to MTX alone.

Objectives:

The aim of this study is to retrospectively analyse and compare the benefit of a treatment with methotrexate (MTX) alone or combined with a bDMARD as an induction therapy during 5 years of follow-up in early rheumatoid arthritis (ERA) patients.

Methods:

We included ERA patients from the UCLouvain Brussels cohort who met the ACR/EULAR 2010 classification criteria and were naïve to DMARDs. Treatments were initiated based on the decision of a senior rheumatologist. bDMARDs induction therapy was usually limited to 6 or 12 months. We collected patient characteristics at baseline and clinical response was analysed at 6 months, 1 year, 3 years and 5 years.

Results:

Data from 470 eligible ERA patients were collected. The average age of the population is 48.9 years; 70.5% of the patients are women; 27.3% are smokers and 68.8% are positive for anti-citrullinated protein antibody (ACPA). 281 patients (59.8 %) initiated MTX as a monotherapy (MTX group) compared to 189 patients (40.2%) who received a bDMARD (Bio group).

At baseline, the disease activity is the main factor that favors the initiation of bDMARDs (DAS28-CRP 5.2 vs 4.5, p<0.001) followed by HAQ (1.32 vs 1.15, p=0.009), ACPA positivity (77.8% vs 62.5%, p=0.0006), rheumatoid factor positivity (71.5% vs 60.2%, p=0.0134). Other parameters such as age, gender, smoking habits or baseline erosion were similar between groups.

391 patients were followed up to 5 years. We then divided each of the two groups into two subgroups according to the last treatment they received at 5 years. Figure 1 shows the percentage of DAS28-CRP remission during time in each of the four groups (MTX->MTX (n=134), MTX->BIO (n=103); BIO->MTX (n=95), BIO->BIO (n=59);

Figure 1.

DAS28-CRP remission rate during time in each of the four groups (MTX->MTX (n=134), MTX->BIO (n=103); BIO->MTX (n=95), BIO->BIO (n=59).

At 12 months, DAS28-CRP response rate was statistically significantly higher in MTX>MTX and BIO>MTX groups compared to the two other groups. As expected, the remission rate was rescued in the group MTX->Bio after 12 months.

Interestingly, ERA patients initially treated by a bDMARD followed by a MTX maintenance therapy experienced a stable and sustained rate of remission.

Conclusion:

Longterm remission is an achievable goal in ERA followed in daily clinic. Our results suggest that a bDMARD induction therapy followed by MTX maintenance therapy could be a good option in severe case of ERA.

References:

[1]Smolen JS and al. D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020 Jan 22.

Disclosure of Interests:

None declared

POS0067 HIGH DEGREE OF INTER-PATIENT HETEROGENEITY IN SYNOVIOCYTE HYPERPLASIA AND IMMUNE CELLS INFILTRATION IN THE SYNOVIUM OF JUVENILE IDIOPATHIC ARTHRITIS PATIENTS

Background:

Increasing evidence indicates that synovial tissue analysis can deliver pathophysiological insights but also individual clinically-relevant information in adult-onset inflammatory arthritides. Little is known about synovial pathology in juvenile idiopathic arthritis, especially regarding inter-patient variability of histopathological features.

Objectives:

To assess the heterogeneity of main synovial features (synoviocyte hyperplasia and immune cells infiltration) in juvenile idiopathic arthritis (JIA) patients and a cohort of young adults (<30 years old) with early rheumatoid arthritis (RA).

Methods:

Synovial biopsies were sampled using needle arthroscopy or ultra-sound (US) guided biopsy during intra-articular joint injection. Tissue was embedded in paraffin then sections were stained with hematoxylin and eosin. Synoviocyte hyperplasia (SH) and immune cells infiltration (ICI) was assessed by an experienced pathologist on a 0 – 3 scale where 0 represents the absence of the feature and 3 the highest level.

Results:

34 JIA patients (age (median ±SD): 15.5±6.47 years, oligo-articular JIA n=28/34, polyarticular JIA n=6/34, ANA-RF-ACPA positivity=56%-10%-3%) and 22 RA (age (median ±SD): 24.3±2.6 years, ANA-RF-ACPA positivity=10%-36%-32%) patients were included. Synovial tissue was obtained from knee (n=49/56), wrist (n=4/56) or metacarpophalangeal/intercarpophalangeal joints (n=3/56), using US guided biopsy in 27% of patients and needle arthroscopy in 73%.

Individual scores of SH and ICI were correlated in both JIA (Spearman’s r=0.503, p value=0.0024) and RA (Spearman’s r=0.636, p value=0.0015). There was no significant difference in SH and ICI scores between the 2 groups (SH score (Q25-Q50-Q75) in JIA= 0.5-1.125-2 and in RA = 0.75-2-2; ICI score (Q25-Q50-Q75) in JIA= 1-2-2 and in RA = 0.75-2-2.25). Intra-group variability of the two assessed features was comparable between the 2 groups (SH coefficient of variation: 72.2% for JIA and 68.2% for RA; ICI coefficient of variation: 52.2% for JIA and 71.2% for RA). Within JIA patients, there was no significant difference in SH/ICI scores between groups based on ANA positivity, oligo or polyarticular involvement nor ongoing treatment.

Conclusion:

Studying main histological features of synovitis, we found no difference between JIA and young RA patients. Furthermore, we report a similar degree of inter-patient heterogeneity in synovial pathological features of JIA and RA patients. These variations were not explained by common clinical characteristics. Whether they relate to different molecular signatures as suggested in adult RA will be further investigated using bulk tissue RNA sequencing.

Acknowledgements:

This work was funded in part by Cap48 (RTBF). Clément Triaille is funded by the Fonds National de la Recherche Scientifique (FNRS, Communauté française de Belgique) and Fondation Saint-Luc (Cliniques Universitaires Saint-Luc).

Disclosure of Interests:

Clément Triaille: None declared, Cécile Boulanger: None declared, Tatiana Sokolova: None declared, Laurent Meric de Bellefon: None declared, Adrien Nzeusseu Toukap: None declared, Christine Galant: None declared, Nisha Limaye: None declared, Bernard Lauwerys Employee of: currently employed at UCB Biopharma, Patrick Durez: None declared.

Diagnostic performance of sacroiliac joint MRI and added value of spine MRI to detect active spondyloarthritis

PURPOSE

To investigate the diagnostic performance of sacroiliac joint (SIJ) magnetic resonance imaging (MRI) and the incremental value of spine MRI to "predict" clinical disease activity in patients with axial spondyloarthritis (axSpA).

MATERIALS AND METHODS

This cross-sectional study included adult patients with known axSpA according to the SpondyloArthritis International Society (ASAS) classification criteria, radiological arm. MRI disease activity was scored semi-quantitatively for SIJ and total spine MRI in each patient. Two cut-off levels (≥ 1.3 and ≥ 2.1) for ankylosing spondylitis disease activity score with C-reactive protein (ASDAS-CRP) were considered for clinical disease activity categorization. MRI scores were first evaluated individually. Then, SIJ score was combined with the score from a spine segment (lumbar, cervical, thoracic or total spine) to build a bi-parametric model using a classification tree. Receiver operating characteristic (ROC) curves were constructed to evaluate the classification performance according to disease activity category of these models.

RESULTS

Forty-four patients (30 men, 14 women; mean age, 37 years±10 [SD] [range: 17-64 years]) with a mean disease duration of 5 years±8 (SD) (range: 0-35 years) were included. Thirty-six patients (36/44; 82%) had ASDAS-CRP≥1.3 and 27 patients (27/44; 61%) had ASDAS-CRP≥2.1. The most frequently involved spinal segment was mid-thoracic (T7-T8). The SIJ MRI score was an informative model to identify active axSpA (AUC≥0.7, regardless of the cut-off level on ASDAS-CRP). Performance of bi-parametric models based on "SIJ+thoracic spine" (for detecting patients with ASDAS-CRP≥1.3) or "SIJ+total spine" (for detecting patients with ASDAS-CRP≥2.1) outperformed that of the individual SIJ score (P<0.05).

CONCLUSION

The combination of MRI of the SIJ and spine allows to accurately discriminate between active and inactive axSpA, outperforming SIJ MRI alone.

FRI0268 REMISSION IN AXIAL SPONDYLOARTHRITIS: IS THERE A DIFFERENCE BETWEEN NSAIDS AND BIOLOGICS IN THE REAL LIFE?

Background:

Randomized-controlled trials (RCTs) done in axial spondyloarthritis (AxSpA) patients have shown that remission in AxSpA and nonradiographic axial SpA patients treated without biologics (BIOL) occurs infrequently (Ref 1, 2). Few are known about remission rate (RR) in daily clinical practice.

Objectives:

Our aim was to assess the remission rate (RR) in AxSpA patients in Real life, and to compare the RR in AxSpA patients on NSAIDs to RR for those on Biologics (TNFα blockers or IL-17A blockers).

Methods:

This cross-sectional study reviewed clinical data from a single center (St-Luc university hospitals, UCLouvain, Brussels) from 01/2013 to 03/2019. Last visit available for clinical assessment was evaluated. Disease activity was measured using the Bath Ankylosing Spondylitis disease activity index (BASDAI), and the Ankylosing Spondylitis disease activity score (ASDAS) using the C-reactive protein. Remission was defined as BASDAI < 4 and ASDAS < 1.3.

Results:

Data from 551 AxSpA patients were reviewed. 353 were men (64.3%). In the entire cohort, 478 BASDAI and 317 ASDAS were recorded. The RR according to the BASDAI was 46.7% (n = 223), and 17.3% for the ASDAS (n = 55). To look for the treatment-related RR, we stratified by the treatment (NSAIDs vs Biologics). We had 285 patients on NSAIDs (177 men, 62.5%) and 266 on BIOL (176 men, 66%). 245 BASDAI were available for NSAIDs and 233 for BIOL. 110 patients on NSAIDs (44.9%) and 113 on BIOL (48.5%) were in remission for BASDAI. Regarding ASDAS (table below), data from 172 patients on NSAIDs and 144 on BIOL were available. Out of them, 27 (15.7%) and 28 (19.4%) were in remission for NSAIDs and BIOL respectively. Chi-square test: p = 0.853.

Table.

Distribution of ASDAS values in both groups.

ASDAS<1.3ASDAS≥ 1.3 < 2.1ASDAS≥ 2.1 < 3.5ASDAS> 3.5NSAIDs (n = 172)N = 27 (15.7%)N = 41 (23.8%)N = 70 (40.7%)N = 34 (19.8%)BIOL (n = 144)N = 28 (19.4%)N = 30 (20.8%)N = 57 (39.6%)N = 29 (20.1%)

Conclusion:

The real life RR in AxSpA seems to be higher on BIOL, even if compared to NSAIDs, the difference is not significant. However, many patients on NSAIDs achieve the remission.

References:

[1]Deodhar A. et al. Arthritis Rheumatol 2019 Jul;71(7):1101-1111. 2) Sieper J. et al. Rheumatology (Oxford) 2016 Nov; 55(11): 1946-1953.

Disclosure of Interests:

Charlotte Baert: None declared, Charlene MOUAFO TOUKAM: None declared, Tatiana Sokolova: None declared, Adrien Nzeusseu Toukap Grant/research support from: AbbVie, Celgene Corporation, Janssen, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, UCB – consultant, Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, UCB – advisory board member

OP0055 MINIMAL RADIOGRAPHIC DAMAGE OF SACROILIAC JOINTS DETECTED IN PSORIATIC ARTHRITIS PATIENTS

Background:

Psoriatic arthritis (PsA) is an inflammatory joint disease that is traditionally included in the Spondyloarthritis (SpA) spectrum. Prevalence and impact of axial involvement in PsA remains understudied but increasingly affects treatment decisions.

Objectives:

The first step, in this multi-purpose radiographic study, is to report on baseline radiographic damage of the sacroiliac joints (SIJ) in PsA patients from a prospective multicentre cohort study in private and academic rheumatology practices.

Methods:

Data from the Belgian Epidemiological Psoriatic Arthritis Study (BEPAS), a prospective multicentre cohort involving 17 Belgian rheumatology practices. Recruitment was from December 2012 until July 2014. Patients were included in the study when the local rheumatologist could diagnose an existing or new PsA and when patients fulfilled the Classification criteria for Psoriatic Arthritis (CASPAR). Radiographs of the SIJ were obtained at baseline and after 2 years. Two calibrated readers assessed radiographic damage by grading the SIJ according to the modified New York (mNY) criteria. When assessing the images, readers were blinded for clinical data and information from other obtained images (radiographs of the hands, feet and spine). Individual scores as well as consensus scores are described.

Results:

In total 461 patients where included in BEPAS. Mean age was 52.79±12.29 years and 43.0% (n=198) were female; average disease duration was 8.5 ± 9.3 yrs and approximately 34% of the patients report inflammatory axial pain. From 338 patients SIJ radiographs were obtained. At baseline, the vast majority of patients did not fulfil the mNY criteria (n=325, 96.2%), according to both readers. In 8 cases (2.4%) there was concordance on fulfilment of the mNY criteria. Discordant cases (n=5, 1.4%) were equally distributed. Agreement between the 2 readers was good with 98.5% overall agreement and kappa=0.75. Therefore, with a more sensitive approach (any of the 2 readers scores mNY positive) we see slight differences; 13 patients (3.8%) fulfil the mNY criteria. Table 1 shows radiographic damage by individual readers

Table.

Baseline data on radiographic damage of the sacroiliac joints in Belgian patients with newly diagnosed or existing PsA included in the BEPAS.

N=338Right sacroiliac jointLeft sacroiliac jointGradesType of lesionReader 1Reader 2Reader 1Reader 20No abnormalities298 (88.2%)301 (89.1%)298 (88.2%)296 (87.6%)1Indefinite abnormalities32 (9.5%)23 (6.8%)27 (8.0%)23 (6.8%)2-3Abnormalities5 (1.5%)12 (3.6%)9 (2.7%)19 (5.6%)Erosion3 (0.9%)11 (3.3%)4 (1.2%)18 (5.3%)Sclerosis4 (1.2%)12 (3.6%)5 (1.5%)13 (3.9%)Joint space alteration (narrowing or widening)1 (0.3%)1 (0.3%)4 (1.2%)2 (0.6%)Partial ankylosis2 (0.6%)3 (0.9%)5 (1.5%)8 (2.4%)4Total ankylosis3 (0.9%)2 (0.6%)4 (1.2%)-

In 128 patients (37.9%) a follow-up x-ray after 2 years was available. In 124 patients (96.9%) there was reader agreement on mNY negative status. There was disagreement between readers on a positive mNY in 2 patients (equally distributed) and agreement on 2 patients (1.6%). There were no patients with consensus between readers on the change in mNY over 2 years, but 1 reader reported 1 patient becoming mNY positive after 2 years.

Conclusion:

Despite the patient self-identified presence of axial disease in up to 34% in this cohort of PsA patients, there was minimal radiographic damage on SIJ, suggesting that SIJ disease is not a major manifestation of PsA.

Disclosure of Interests:

Manouk de Hooge: None declared, Alla Ishchenko: None declared, Serge Steinfeld: None declared, Adrien Nzeusseu Toukap Grant/research support from: AbbVie, Celgene Corporation, Janssen, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, UCB – consultant, Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, UCB – advisory board member, Dirk Elewaut: None declared, Hermine Leroi Employee of: MSD Belgium, Rik Lories Grant/research support from: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – grant/research support (on behalf of Leuven Research and Development), Consultant of: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – consultant (on behalf of Leuven Research and Development), Speakers bureau: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – speaker (on behalf of Leuven Research and Development), Kurt de Vlam Grant/research support from: Celgene, Eli Lilly, Pfizer Inc, Consultant of: AbbVie, Eli Lilly, Galapagos, Johnson & Johnson, Novartis, Pfizer Inc, UCB, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB

AB0758 REAL-WORLD EFFICACY AND SAFETY OF APREMILAST IN BELGIAN PATIENTS WITH PSORIATIC ARTHRITIS: FINAL ANALYSIS OF THE MULTICENTRE, PROSPECTIVE APOLO STUDY

Background:

Real-world evidence on the efficacy and safety for patients (pts) with psoriatic arthritis (PsA) treated with apremilast (APR) is lacking but required to understand the uptake and potential of the drug.

Objectives:

To assess the efficacy and safety of APR in pts with active PsA from routine clinical practice in Belgium.

Methods:

In this multicentre, prospective study, the primary endpoint was the PsA Response Criteria (PsARC) response 6 months after APR initiation, defined as improvement in ≥2 (at least 1 must be joint swelling or tenderness) and no worsening in any of 4 criteria: swollen joint count (SJC [0-66]), tender joint count (TJC [0-68]), Physician’s Global Assessment of Disease Activity and Pt’s Global Assessment of Disease Activity. Other endpoints included the 12-item PsA Impact of the Disease (PsAID12) questionnaire, Health Assessment Questionnaire-Disability Index (HAQ-DI), Physician’s and Pt’s Numerical Rating Scale assessing disease activity for the most affected joint, psoriasis-involved body surface area, enthesitis, dactylitis and pain.

Results:

In total, 107 pts were enrolled and included in the baseline (BL) demographics/disease characteristics and safety analyses. The efficacy population comprised 69 pts (pts who started APR ≤30 days before inclusion in the study and completed ≥150 days of treatment). Mean age was 53 years, mean body mass index was 29 kg/m2and 56% were female. Mean duration of PsA was ≈8 years (87.1 months). One-third of pts presented with short disease duration (time since diagnosis of PsA: ≤2 years); 84% were biologic naive. The most frequently reported comorbidities were cardiovascular disease (30%) and hypercholesterolemia (24%). At BL, mean (SD) SJC was 8.0 (6.5); mean (SD) TJC was 14.2 (12.5). Pts from the efficacy population were representative of the overall population. Fifty-four pts (60%) continued APR treatment for 6 months; 38 (36%) had discontinued APR (insufficient efficacy: n=15; adverse events [AEs]: n=16; intolerance: n=6; other reason: n=1). AEs were mostly mild or moderate in nature and consistent with APR’s known safety and tolerability profile.1At Month 6, data were available for 49 pts, 65% of whom were PsARC responders. Mean change from BL in SJC was −5.23, with improvements (defined as ≥30% decrease per PsARC) observed in 80% of pts; 42% had no swollen joints at 6 months. Comparable results were seen for TJC, with mean changes from BL of −5.34 and improvements observed in 71% of pts; 27% had no tender joints at 6 months. Among pts with enthesitis at BL (n=21), 43% achieved a score of 0 by Month 6. Among pts with dactylitis at BL (n=18), 83% achieved a count of 0 by Month 6. Impact of PsA on quality of life (QoL) from the pt’s perspective was assessed using the PsAID12 questionnaire and characterized by physical and psychological domains. After 3 and 6 months of treatment, 33% and 50% of pts with PsAID >4 at BL (n=60) achieved PsAID12 ≤4, respectively (cutoff value for Pt Acceptable Symptom State2). Improvements were observed in all 12 domains at Months 3 and 6 compared with BL (Figure). In all, 66% of pts showed a decrease ≥0.35 in HAQ-DI; the proportion of pts reaching a global HAQ-DI <0.5 increased over time (14% at 3 months; 20% at 6 months).

Conclusion:

Results from APOLO, a study assessing the impact of APR in routine settings, indicated that APR is associated with rapid and sustained improvements in PsA signs and symptoms and QoL in an important proportion of pts. Safety and tolerability were consistent with the known profile of APR.

References:

[1]Kavanaugh A, et al. Arthritis Res Ther. 2019;21:118. 2. Gossec L, et al. Ann Rheum Dis. 2014;73:1012-1019.

Disclosure of Interests:

Kurt de Vlam Consultant of: Celgene Corporation, Eli Lilly, Novartis, Pfizer, UCB – consultant, Speakers bureau: Celgene Corporation, Eli Lilly, Novartis, Pfizer, UCB – speakers bureau and honoraria, Adrien Nzeusseu Toukap Grant/research support from: AbbVie, Celgene Corporation, Janssen, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, UCB – consultant, Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, UCB – advisory board member, Marie-Joëlle Kaiser Consultant of: Celgene Corporation – consultant, Johan Vanhoof: None declared, Philip Remans: None declared, Silvana Di Romana: None declared, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Virginie Vanhoof Employee of: Amgen Inc. – employment; Celgene BeLux – employment at the time of study conduct, Rik Lories Grant/research support from: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – grant/research support (on behalf of Leuven Research and Development), Consultant of: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – consultant (on behalf of Leuven Research and Development), Speakers bureau: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – speaker (on behalf of Leuven Research and Development)

FRI0021 SHOULD WE USE GLUCOCORTICOID IN EARLY RHEUMATOID ARTHRITIS?: RESULTS AT 5 YEARS FROM THE ERA LOUVAIN BRUSSELS COHORT

Background:

The EULAR recommendations, updated in 2016, propose the initiation of glucocorticoid (GC) therapy in combination with cDMARDs background therapy for every patient with early rheumatoid arthritis (ERA).1

Objectives:

The aim of this study is to evaluate the proportion of patients with ERA who have been treated with GC in daily practice, to analyse the baseline characteristics of these patients, and to assess the clinical benefit and side effects of GC during 5 years of follow-up.

Methods:

We included patients with ERA from the UCLouvain Brussels cohort who met the ACR/EULAR 2010 classification criteria and were naïve to cDMARDs. Treatments were initiated based on the decision of a senior rheumatologist. We retrospectively collected patient characteristics prior to the introduction of cDMARDs with or without GC. Efficiency and serious adverse events were analysed at 6 months, 1 year, 3 years and 5 years.

Results:

Data from 474 eligible ERA patients were collected. The average age of the population is 48.9 years. 70.5% of the patients are women. 27.3% are smokers and 68.8% are positive for anti-citrullinated protein antibody (ACPA).

178 patients (37.7 %) initiated GC compared to 294 patients (62.3%) who received only NSAIDs and/or analgesics in combination with cDMARDs.

At baseline, the elevation of CRP is the main factor that favors the initiation of GC (CRP 2.9 vs 2.0 mg/dl, p = 0.015) followed by smoking habits (34.2% vs 23.3%, p = 0.018), the absence of ACPA (37.2% vs 27.6%, p = 0.037), the prescription of methotrexate as a monotherapy (70.6% vs 50.5%, p <0.001), and the age (50.6 vs 48.0, p = 0.050). Other parameters such as swollen joint count, tender joint count, DAS28-CRP, HAQ or baseline erosion were similar between groups.

5 years follow-up of DAS28-CRP, HAQ or VAS pain values did not differ between the two groups (Fig 1A).

Figure 1.

Comparison of DAS28-CRP and HAQ scores evolution.(A) in two groups of patients: treated with GC (BL-GC Yes) or without GC (BL_GC No) in combination with cDMARDs as first line treatment.(B) in two groups of patients: never treated with GC during 5 years follow-up (No GC/ 5 years) and those who received a high cumulative dose of GC ≥ 1 g/5years (GC>[1G/5years]).

Interestingly, patients not exposed at baseline to GC showed a higher remission rate (DAS28-CRP< 2.6) of 48.4% vs 44.3% at 6 months.

We also analysed a subgroup of patients (n=139) who received a cumulative dose of more than 1 g of prednisolone during the 5 years period. We confirmed the baseline differences for CRP, smoking habits, age and found in this subgroup more males (36.7% vs 28.2%, p=0.021) and higher DAS-28CRP values (5.0 vs 4.7, p=0.048).

During the 5 years follow up, DAS-28CRP, VAS pain and HAQ remained significantly higher leading to a higher number of bioDMARDs prescribed in this group (Fig 1B).

More severe infections were reported in this subgroup (11.5% vs 4.2%). Bone densitometry values, number of fractures, and cardiovascular profiles were similar between groups.

Conclusion:

In our ERA cohort, initiation of GC treatment does not add additional benefit for the short and long-term control of the disease.

GC were more prescribed in seronegative RA patients with higher level of inflammation and we confirm that patients exposed to higher cumulative doses of GC are at higher risk to develop severe infections.

Further studies are needed to support that GC induction therapy should not be offered to all ERA patients.

References:

[1]Smolen JS, Landewé R, Bijlsma J, et al., EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Jun;76(6):960-977.

Disclosure of Interests:

Emilie Sapart: None declared, Tatiana Sokolova: None declared, Stéphanie de Montjoye: None declared, Stephanie Dierckx: None declared, Adrien Nzeusseu Toukap Grant/research support from: AbbVie, Celgene Corporation, Janssen, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, UCB – consultant, Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, UCB – advisory board member, Aleksandra Avramovska: None declared, Bernard Lauwerys: None declared, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi

The role of biochemical of bone turnover markers in osteoporosis and metabolic bone disease: a consensus paper of the Belgian Bone Club

The exact role of biochemical markers of bone turnover in the management of metabolic bone diseases remains a topic of controversy. In this consensus paper, the Belgian Bone Club aimed to provide a state of the art on the use of these biomarkers in different clinical or physiological situations like in postmenopausal women, osteoporosis in men, in elderly patients, in patients suffering from bone metastasis, in patients with chronic renal failure, in pregnant or lactating women, in intensive care patients, and in diabetics. We also gave our considerations on the analytical issues linked to the use of these biomarkers, on potential new emerging biomarkers, and on the use of bone turnover biomarkers in the follow-up of patients treated with new drugs for osteoporosis.

Myeloperoxidase and its products in synovial fluid of patients with treated or untreated rheumatoid arthritis

OBJECTIVE

Plasma and synovial myeloperoxidase (MPO) and its products were strongly associated with osteoarthritis (OA) and rheumatoid arthritis (RA). In addition, it is well known that there is a link between oxidative stress and cytokines. The present study aims at investigating the link between synovial MPO (and its products), interleukin (IL)-18, which is involved in the degradation of articular cartilage in RA, and IL-8, which is involved in recruitment and activation of neutrophils during inflammation. Effects of the treatment of RA on the biological parameters were also investigated.

METHODS

Patients (n = 105) were studied including 39 patients with OA, 33 with RA and 33 with RA receiving a specific treatment. Disease activity score (DAS-28) was calculated whereas MPO antigen/activity, neutrophils, chloro-tyrosine (Cl-Tyr), homocitrulline (Hcit), IL-8, and IL-18 were measured in synovial fluid (SF) and CRP was measured in serum.

RESULTS

DAS-28 and CRP levels were not significantly different between groups. MPO activity, and MPO, Cl-Tyr, and Hcit levels were significantly higher in SF of RA patients than OA patients. MPO specific activity (MPO activity/antigen ratio) was significantly lower in treated than in untreated RA patients as was IL-8. MPO activity and concentration were correlated with IL-8 and IL-18 in untreated but not in treated RA patients.

CONCLUSIONS

MPO level is related to IL-8 and IL-18 levels in untreated RA patients. A link has been shown between treatment and decrease of IL-8, MPO specific activity and Hcit in SF. The causal role of MPO in SF inflammation and how treatment can affect MPO specific activity need further investigations.

Identification of distinct gene expression profiles in the synovium of patients with systemic lupus erythematosus

OBJECTIVE

Synovitis is a common feature of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), but the pattern of joint involvement differs in each disease. This study was undertaken to investigate the global gene expression profiles in synovial biopsy tissue from the swollen knees of untreated SLE patients (n = 6), RA patients (n = 7), and osteoarthritis (OA) patients (n = 6).

METHODS

Synovial biopsy samples were obtained from the affected knees of patients in the 3 groups by needle arthroscopy. Half of the material was used for extraction of total RNA, amplification of complementary RNA, and high-density oligonucleotide spotted hybridization arrays. On the remaining tissue samples, real-time reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemical experiments were performed to confirm the microarray data.

RESULTS

SLE synovial biopsy tissue displayed a significant down-regulation of genes involved in extracellular matrix (ECM) homeostasis and a significant up-regulation of interferon-inducible (IFI) genes. Real-time RT-PCR experiments confirmed the up-regulation of selected IFI genes (IFI27, IFI44, and IFI44L) in the SLE synovial tissue. Immunohistochemical analyses showed that 3 molecules involved in ECM regulation, chondroitin sulfate proteoglycan 2, latent transforming growth factor beta binding protein 2, and fibroblast activation protein alpha, were significantly down-regulated in SLE synovium. In contrast, immunostaining for IFI27, Toll-like receptor 4, and STAT-1 resulted in higher quantitative scores in SLE synovial tissue, which could be attributed to the fact that the RA samples had a large population of inflammatory cell infiltrates that were negative for these markers.

CONCLUSION

Arthritis in SLE has a very distinct molecular signature as compared with that in OA and RA, characterized by up-regulation of IFI genes and down-regulation of genes involved in ECM homeostasis.

A pilot study of mycophenolate mofetil combined to intravenous methylprednisolone pulses and oral low-dose glucocorticoids in severe early systemic sclerosis

OBJECTIVE

This pilot study was aimed at evaluating the efficacy and safety of a protocol-based treatment strategy combining mycophenolate mofetil (MMF), intravenous (IV) methylprednisolone (MP) pulses and low-dose glucocorticoids (GC) in early systemic sclerosis (SSc) patients suffering from either active interstitial lung disease (ILD) or extensive skin disease.

PATIENTS AND METHODS

Sixteen SSc patients were recruited in the study, 9 based on the severity of their skin involvement (modified Rodnan total skin score [TSS] >or= 15) and 7 based on the presence of active ILD. Patients received 3 consecutive daily IV MP pulses, followed by 5 additional monthly IV MP pulses. MMF (0.5 g bid for one week; then, 1 g bid) and low-dose (5-10 mg/day) oral prednisolone were prescribed for one year. Patients were assessed at baseline, month 6 and 12. Statistics were by ANOVA.

RESULTS

TSS and Health Assessment Questionnaire significantly improved over time. In ILD patients, the vital capacity, forced expiratory volume in one second and carbon monoxide diffusing capacity significantly improved. Although the difference was not statistically significant, ground glass lesions decreased, based on semi-quantitative planimetry analyses performed on chest high-resolution computerized tomography. Toxicity was low and none of the patients suffered from renal crisis.

CONCLUSION

The results of this pilot study suggest that the combination of MMF, IV MP and low-dose GC might achieve good clinical, functional and radiological results in patients suffering from severe early SSc.

Oral pamidronate prevents high-dose glucocorticoid-induced lumbar spine bone loss in premenopausal connective tissue disease (mainly lupus) patients

Glucocorticoid (GC)-induced osteoporosis contributes to chronic damage in patients suffering from connective tissue diseases (CTD) such as systemic lupus erythematosus (SLE). In this study, performed in an highly selected cohort of premenopausal female CTD (mostly lupus) patients, given high-dose GC therapy for severe disease, we show that lumbar spine bone loss can be averted by treatment with oral disodium pamidronate combined with calcium salts and vitamin D3 supplements and not by calcium salts and vitamin D3 supplements alone. We stress the need for optimal GC-induced bone loss prevention therapy in premenopausal patients, a too often neglected issue in patients whose survival has dramatically improved over the last decades.

A randomised comparative study of the short term clinical and biological effects of intravenous pulse methylprednisolone and infliximab in patients with active rheumatoid arthritis despite methotrexate treatment

OBJECTIVES

To compare the short term clinical and biological effects of intravenous (i.v.) pulse methylprednisolone (MP) and infliximab (IFX) in patients with severe active rheumatoid arthritis (RA) despite methotrexate (MTX) treatment.

METHODS

Patients with active RA despite MTX treatment were randomly allocated to receive a single i.v. infusion of MP (1 g) or three i.v. infusions of IFX (3 mg/kg) on weeks 0, 2, and 6. Patients were "blindly" evaluated for disease activity measures. Quality of life (QoL) was evaluated through the SF-36 health survey. Serum matrix metalloproteinase-3 (MMP-3) titres were measured at baseline, weeks 2 and 6.

RESULTS

Compared with baseline, significant improvement was noted in all activity measures, including serum C reactive protein (CRP) titres, in the IFX group only. At week 14, 6/9 (67%) and 4/9 (44%) IFX patients met the ACR20 and 50 response criteria, while this was the case in only 1/12 (8%) and 0/12 (0%) MP patients, respectively (p<0.05). None of the QoL scales improved with MP treatment, whereas some did so in the IFX group. Serum MMP-3 titres significantly decreased (41% drop) at week 6 in the IFX group, while no changes were seen in patients given MP.

CONCLUSION

This short term randomised comparative study demonstrates that TNF blockade is better than MP pulse therapy in a subset of patients with severe refractory RA, with improvement in not only clinical parameters of disease activity but also biological inflammatory indices, such as serum CRP and MMP-3 titres.

Nocardiosis: a rare cause of pleuropulmonary disease in the immunocompromised host

We report a case of acute pleuropulmonary nocardial infection in a 24-year-old woman suffering from systemic lupus erythematosus. In most instances, No-cardia asteroides is an opportunistic pathogen. In our patient, the infection was facilitated by systemic lupus erythematosus and chronic use of corticosteroids and immunosuppressive drugs. N. asteroides was cultured from both pleural effusion and blood. No extrathoracic location was found and the patient improved upon intravenous antibiotics and pleural drainage. Owing to the poor tolerance of trimethoprim/sulfamethoxazole, the patient was treated successfully with imipenem. The predisposing factors, the clues to the diagnosis and the therapy of nocardiosis are briefly reviewed.