High Throughput Genetic Characterisation of Caucasian Patients Affected by Multi-Drug Resistant Rheumatoid or Psoriatic Arthritis

Rheumatoid and psoriatic arthritis (RA and PsA) are inflammatory rheumatic disorders characterised by a multifactorial etiology. To date, the genetic contributions to the disease onset, severity and drug response are not clearly defined, and despite the development of novel targeted therapies, ~10% of patients still display poor treatment responses. We characterised a selected cohort of eleven non-responder patients aiming to define the genetic contribution to drug resistance. An accurate clinical examination of the patients was coupled with several high-throughput genetic testing, including HLA typing, SNPs-array and Whole Exome Sequencing (WES). The analyses revealed that all the subjects carry very rare HLA phenotypes which contain HLA alleles associated with RA development (e.g., HLA-DRB1*04, DRB1*10:01 and DRB1*01). Additionally, six patients also carry PsA risk alleles (e.g., HLA-B*27:02 and B*38:01). WES analysis and SNPs-array revealed 23 damaging variants with 18 novel “drug-resistance” RA/PsA candidate genes. Eight patients carry likely pathogenic variants within common genes (CYP21A2, DVL1, PRKDC, ORAI1, UGT2B17, MSR1). Furthermore, “private” damaging variants were identified within 12 additional genes (WNT10A, ABCB7, SERPING1, GNRHR, NCAPD3, CLCF1, HACE1, NCAPD2, ESR1, SAMHD1, CYP27A1, CCDC88C). This multistep approach highlighted novel RA/PsA candidate genes and genotype-phenotype correlations potentially useful for clinicians in selecting the best therapeutic strategy.

Clinical, laboratory and immunohistochemical characterization of in situ pulmonary arterial thrombosis in fatal COVID-19

Background

COVID-19 patients carry an increased rate of thrombosis. It is controversial to which extent thrombi in the pulmonary arterial tree really contribute to disease severity with hypoxemia secondary to microvascular/lung parenchymal damage with viral alveolitis considered to play the main role in critical disease.

Objectives

The primary objective was to compare post-mortem lung disease from fatal COVID-19 pneumonia in patients with macroscopically evident pulmonary arterial tree thrombosis and patients without, by characterizing the immunohistochemical nature of thrombi, and by comparing clinical and laboratory features of these patients with other COVID-19 patients who died but without evidence of pulmonary arterial thrombosis (controls).

Patients and methods

13 COVID-19 pneumonia cases (mean age ± standard deviation: 74 ± 6.5 years) with macroscopically visible pulmonary arterial thrombosis were compared to 14 controls. Hematoxylin and Eosin stained slides were reviewed choosing those with visible pulmonary thrombi which were further characterized by immunohistochemistry, in particular for the inflammatory infiltrates. Ante mortem serum markers relevant to pulmonary embolism were evaluated in both groups.

Results

Twenty arterial thrombi (5 cases with multiple thrombi) were selected for study and were composed by white blood cells (WBC) [median, IQR range: 10 % (5–12.25)], mainly neutrophils [58 % (35.2–64.5)]. Cases with thrombosis showed significantly higher levels of platelet count [median, IQR range: 195000/mmc (157750–274,500) vs 143,500 (113000–175,250), p = 0.011], LDH [854 U/L (731–1315) vs 539 (391.5–660), p = 0.003] at admission, and D-dimer at ICU transfer [25,072 FEU (6951–50,531) vs 1024 (620–5501), p = 0.003].

Conclusions

Immunothrombotically driven arterial thrombi in COVID-19 patients are associated with D-Dimer and LDH elevations, thus linking inflammation, coagulopathy and organ damage in fatal COVID-19.

AB1125 SAFETY OF BIOLOGIC-DMARDs DURING COVID-19 OUTBREAK: FOLLOW-UP STUDY IN 1051 RHEUMATIC PATIENTS OVER THE FIRST TWO WAVES

Background

A novel viral infection known as COVID-19 (Coronavirus-19 disease) spread up in Wuhan (China) in December 2019, but rapidly diffused worldwide and nowadays it remains an international health problem. Because of its impact on immunologic system, immunomodulating therapies have been studied as possible treatments for severe cases of COVID-19. In that context, patients affected by from rheumatic musculoskeletal disorders (RMD) under disease modifying anti-rheumatic drugs (DMARDs) have been observed in several studies to evaluate the impact of COVID-19 on these subjects, well known to be at higher risk of infection.

Objectives

The primary objective of this study is to assess prevalence and severity of COVID-19 in patients with RMD under treatment with biologic (b-DMARDs) or targeted synthetic (ts-DMARDs) DMARDs, before the vaccination campaign. The second aim is to compare those data with that in general population of the same Area (Province of Udine, Friuli Venezia Giulia Region, Italy,).

Methods

A cohort of RMD patients treated with b-DMARDs or ts-DMARDs was observed from September 2019 to November 2020. Both pandemic waves have been considered, until the start of vaccination (since current variants can overcome vaccine protection), between February 2020 and April 2020 (first wave) and between September 2020 and November 2020 (second one).

Results

Among 1051 RMD patients treated with b- or ts-DMARDs COVID-19 prevalence was 3.5% (37 cases) without significant differences compared to general population of the same Region (Table 1). Infected patients were 18 men and 19 women, with a median age of 60 years (IQR 49-68). Notably, the infection rate of RMD patients was significantly lower compared to the general population of the same province, particularly during the second wave (p<0.001, Table 1). Almost all patients reported fever (70%). Gastro-intestinal symptoms (nausea, vomit and diarrhoea) have been recorded in 10 subjects (27%) and resulted significantly associated with longer swab positivity (p<0.05) (Figure 1). Only a small percentage of patients with COVID-19 infection was receiving corticosteroids (8%), and the doses were low (3.5 or 5 mg per day of prednisone equivalents). The most used b-DMARDs were anti-TNFs (24/37, 65%), while just 4/37 (11%) employed JAK inhibitors. A small percentage of patients (6/37, 16%) continued ongoing treatment, with no worsened outcomes, while none preventively suspended the immunosuppressant. The course of infection was generally benign with a mortality rate of 2.6% (1 patient, with several risk factors) and only 9 patients needed to be hospitalized (24%). After COVID-19 infection, 12 subjects (32%) had RMD flare and 5 of them subsequently needed to change the immunosuppressive drug.

Figure 1.Table 1.

Cases and proportion of COVID-19 among different populations. *p<0.001, patients vs province population; °p<0.05 patients vs province population.

Cases (proportions)PeriodsRMD patientsProvince populationRegion populationOverall wave37 (0.0352)*14437 (0.1441)32970 (0.0273)First wave5 (0.0048)°1190 (0.0119)3769 (0.0031)Second wave32 (0.0304)*13247 (0.1322)29201 (0.0242)

Conclusion

The prevalence of COVID-19 in RMD patients has been confirmed low in both waves and it could be partially explained by the great awareness about preventive strategies by the patients. The benign course of COVID-19 in our patients may be linked to the very low amount of chronic corticosteroids used and the possible protective effect of anti-TNF agents, which were the main class of biologics herein employed. Gastro-intestinal symptoms might be a predictor of viral persistence in immunosuppressed patients. This finding could be useful to identify earlier COVID-19 carriers with uncommon symptoms (without respiratory manifestations), eventually eligible for antiviral drugs.

References

[1]Gianfrancesco M et al. DOI 10.1136/annrheumdis-2020-217871

Disclosure of Interests

None declared

AB1162 THE LINK BETWEEN INFLAMMATION AND THROMBOSIS: CLINICAL AND IMMUNOHISTOCHEMICAL CHARACTERIZATION OF PULMONARY ARTERIAL THROMBOSIS IN COVID-19 PATIENTS

Background

Coronavirus-19 disease (COVID-19) has been responsible, to date, for more than 5 million of deaths. Immunothrombosis may be a major factor contributing to mortality in COVID-19 and pulmonary arterial tree involvement that mimics multiple pulmonary embolism could be a major contributor to disease course. Immunomodulatory drugs are of some benefit but mechanism not completely clear. We investigated pulmonary arterial tree clots to better appreciate their immunothrombotic nature, in contrast to the pathological characteristics of non-inflammatory thrombi (1).

Objectives

The primary objective was to study in depth the arterial thrombosis in COVID-19, by characterizing the immunohistochemical nature of thrombi, performing macroscopic and microscopic analyses, and by comparing clinical, laboratory and anatomical-pathological data of these patients with other patients died for COVID-19 but without evidence of pulmonary arterial thrombosis.

Methods

Autopsies were performed in patients (cases) who died for COVID-19 with evidence of pulmonary arterial thrombosis at autopsy finding but without pathological signs of bronchopneumonia or peripheral venous thrombosis. COVID-19 positive patients without pulmonary arterial thrombosis were selected as control group. Hematoxylin and eosin stained slides were reviewed choosing those with visible pulmonary thrombi. Further histochemical and immunohistochemical staining were performed in selected paraffin blocks. Each component of the thrombus was evaluated with the software application QuPath in terms of fibrin, red blood cells, platelets and immune cells percentage after scanning the slides with Aperio System. Laboratory tests were recorded at 2 points: at hospital admission and at Intensive Care Unit transfer.

Results

We included 13 patients (cases) and 14 controls, matched for age, gender and time from diagnosis to death. Twenty arterial thrombi were studied. By immunohistochemistry, arterial thrombi were composed by white blood cells (WBC) [median, IQR range: 10% (5-12.25)], mainly neutrophils [58% (35.2-64.5)], red blood cells [12%, (6-34.25)], fibrin [19% (14.5-42.25)], platelets [39%, (31.75-48)] (Figure 1). Three cases had a history of previous thrombosis. All cases had received anticoagulant treatment during hospitalization, low molecular weight heparin in 12/13 (therapeutic regimen in 4/12, prophylactic in 8/12) while 1/13 continued oral anticoagulants for comorbidity. By comparing laboratory findings between cases and controls, cases showed significantly higher levels of platelet count [median, IQR range: 195000/mmc (157750-274500) vs 143500 (113000-175250), p=0.011], LDH [854 U/l (731-1315) vs 539 (391.5-660), p=0.003)] at hospital admission, and D-dimer at ICU transfer [25072 FEU (6951-50531) vs 1024 (620-5501), p=0.003)].

Figure 1.

Conclusion

Pulmonary arterial thrombosis in COVID-19 is a type of immune-mediated inflammatory thrombosis, since the amount of WBC is 6-times more than normal value seen in non-inflammatory thrombi. Some markers of inflammation, necrosis and coagulation are much more increased in this subset of patients. Chest CT angiography rather than simple CT scan at hospital admission could be more useful in this setting, and treatments with antiplatelet agents or anticoagulants, eventually in combination with immunotherapy, might positively affect the outcome.

References

[1]Chernysh IN, et al. The distinctive structure and composition of arterial and venous thrombi and pulmonary emboli. Sci Rep. 2020;10(1):5112.

Disclosure of Interests

None declared

Interleukin 6, soluble interleukin 2 receptor alpha (CD25), monocyte colony-stimulating factor, and hepatocyte growth factor linked with systemic hyperinflammation, innate immunity hyperactivation, and organ damage in COVID-19 pneumonia

Background

Patients infected by SARS-CoV-2 can develop interstitial pneumonia, requiring hospitalisation or mechanical ventilation. Increased levels of inflammatory biomarkers are associated with development of acute respiratory distress syndrome (ARDS). The aim of the present study was to determine which cytokines are associated with respiratory insufficiency in patients hospitalised for COVID-19.

Patients and methods

Data on 67 consecutive patients were collected between March 8 and March 30, 2020. PaO₂/FiO₂ ratio (P/F) was calculated at hospital admission. The following cytokines were analysed: interleukin (IL)-6, IL-1α, IL-18, tumour necrosis factor (TNF)-β, macrophage colony-stimulating factor (M-CSF), macrophage migration inhibitory factor (MIF), soluble IL-2 receptor alpha (sIL-2Rα; CD25), IL-12β, IL-3, interferon (IFN) α2a, monokine induced by gamma interferon (MIG), monocyte-chemotactic protein 3 (MCP3) and hepatocyte growth factor (HGF).

Results

P/F lower than 300 was recorded in 22 out of 67 patients (32.8%). P/F strongly correlated with IL-6 (r = −0.62, P < 0.0001), M-CSF (r = −0.63, P < 0.0001), sIL-2Rα (r = −0.54, P < 0.0001), and HGF (r = −0.53, P < 0.0001). ROC curve analyses for IL-6 (AUC 0.83, 95% CI 0.73–0.93, P < 0.0001), M-CSF (AUC 0.87, 95% CI 0.79–0.96, P < 0.0001), HGF (AUC 0.81, 95% CI 0.70–0.93, P < 0.0001), and sIL-2Rα (AUC 0.80, 95% CI, 0.69–0.90, P < 0.0001) showed that these four soluble factors were highly significant. All four soluble factors correlated with LDH, white blood cell count, neutrophil count, lymphocyte count, and CRP.

Conclusion

IL-6, M-CSF, sIL-2Rα, and HGF are possibly involved in the main biological processes of severe COVID-19, mirroring the level of systemic hyperinflammatory state, the level of lung inflammation, and the severity of organ damage.

Profiling COVID-19 pneumonia progressing into the cytokine storm syndrome: Results from a single Italian Centre study on tocilizumab versus standard of care

OBJECTIVE

Approximately 5% of patients with coronavirus disease 2019 (COVID-19) develop a life-threatening pneumonia that often occurs in the setting of increased inflammation or "cytokine storm". Anti-cytokine treatments are being evaluated but optimal patient selection remains unclear, and the aim of our study is to address this point.

METHODS

Between February 29 to April 6, 2020, 111 consecutive hospitalized patients with COVID-19 pneumonia were evaluated in a single centre retrospective study. Patients were divided in two groups: 42 severe cases (TOCI) with adverse prognostic features including raised CRP and IL-6 levels, who underwent anti-cytokine treatments, mostly tocilizumab, and 69 standard of care patients (SOC).

RESULTS

In the TOCI group, all received anti-viral therapy and 40% also received glucocorticoids. In TOCI, 62% of cases were ventilated and there were three deaths (17.8 ± 10.6 days, mean follow up) with 7/26 cases remaining on ventilators, without improvement, and 17/26 developed bacterial superinfection. One fatality occurred in the 15 TOCI cases treated on noninvasive ventilation and one serious bacterial superinfection. Of the 69 cases in SOC, there was no fatalities and no bacterial complications. The TOCI group had higher baseline CRP and IL-6 elevations (p < 0.0001 for both) and higher neutrophils and lower lymphocyte levels (p = 0.04 and p = 0.001, respectively) with the TOCI ventilated patients having higher markers than non-ventilated TOCI patients.

CONCLUSION

Higher inflammatory markers, more infections and worse outcomes characterized ventilated TOCI cases compared to ward based TOCI. Despite the confounding factors, this suggests that therapy time in anti-cytokine randomized trials will be key.

Higher levels of IL-6 early after tocilizumab distinguish survivors from nonsurvivors in COVID-19 pneumonia: A possible indication for deeper targeting of IL-6

Introduction

The most serious COVID‐19 deriving from severe acute respiratory syndrome coronavirus 2 causes a cytokine release storm and it is associated with worse outcomes. In COVID‐19 patients, interleukin‐6 (IL‐6) levels are significantly elevated. Blocking IL‐6 preliminarily resulted in the improvement of this hyperinflammatory state. It is unknown which patients could require higher doses of tocilizumab to get out of the cytokine storm.

Materials and Methods

Twenty‐four patients affected by COVID‐19 pneumonia were included. All the patients underwent tocilizumab 8 mg/kg intravenously and were tested for serum IL‐6 24 to 48 hours before and 12 to 48 hours after tocilizumab infusion. Comparisons between survivors and nonsurvivors were performed.

Results

Eighteen patients were discharged, while six patients died, with no clinical or laboratory differences between the two groups at baseline. IL‐6 was not different at baseline (P = .41), while 24 to 48 hours post‐tocilizumab IL‐6 serum levels were significantly higher in nonsurvivors than in survivors (2398.5 [430.5‐9372] vs 290.5 [58.5‐1305.5] pg/mL, P = .022). Serum IL‐6 post‐tocilizumab showed a good predictive ability to discriminate survivors from nonsurvivors (area under the curve, 0.815; 95% confidence interval, 0.63‐0.99, P = .02).

Conclusion

Repeated measurement of the serum level of IL‐6 early after tocilizumab may distinguish nonsurvivors from survivors and support the choice of deeper targeting IL‐6 in COVID‐19 pneumonia.

IL‐6 could be a useful biomarker for severity of COVID‐19.

The highest burden of inflammation may be revealed by IL‐6 levels after tocilizumab.

IL‐6 levels before and after tocilizumab may indicate how to improve IL‐6 targeting therapy in COVID‐19.

AB0601 RAPID AND SUSTAINED EFFICACY OF AN INDUCTION TREATMENT WITH A TRIPLE THERAPY INCLUDING HIGH-DOSE INTRAVENOUS IMMUNOGLOBULINS, METHOTREXATE AND GLUCOCORTICOIDS IN ANTI-3-HYDROXY-3-METHYLGLUTARYL-COENZYME A REDUCTASE MYOPATHY

Background:

Anti-3-hydroxy-3-methylglutaryl-coenzime A reductase (HMGCR) myopathy is a new entity, which has been clearly associated to statin use, even if it can be diagnosed in patients without a history of exposure to statin or even in the childhood (1).

Objectives:

The aim of the study is to describe the efficacy of a triple therapy regimen consisting in high-doses of intravenous immunoglobulins (IVIG), methotrexate (MTX), and glucocorticoids (GC) in 16 patients with Anti-HMGCR myopathy enrolled in 6 specialized centres.

Methods:

A total of 16 patients with anti-HMGCR myopathy (7 females; 9 males) were collected. Mean (±standard deviation) age at the onset of disease was 72.4±10.3 years old. All patients were diagnosed having anti-HMGCR myopathy [anti-HMGCR antibodies were measured by chemiluminescence assay (BioFlash, Inova, CA)] (2). Median follow-up was 29.5 months (interquartile range: 15.75-60 months). Anti-HMGCR antibodies were available in the follow-up in 8/16 patients.

Results:

Thirteen out of 16 patients (81.3%) had been exposed to statin (1/13 to red rice), 3/16 (18.7%) were not exposed. As induction therapy, 11/16 patients have been treated with triple therapy (high-dose IVIG, MTX and GC), 2/16 with double therapy (high-dose IVIG and GC), 2/16 have been treated with GC alone, the patient exposed to red rice resolved only with red rice suspension. Clinical remission and normalization of CPK values within month +24 were obtained in all the patients. All the patients were in remission at the last follow-up. Gradual improvement started soon from the first month, and among the 13 patients treated with an aggressive immunosuppresssive therapy including IVIG (13/13), GC (13/13) and methotrexate (11/13), 9/13 normalized the CPK value within 6 months. Clinical and laboratory response was accompanied by significant decrease or normalization of the anti-HMGCR antibody titer. All the patients were either not taking GC (56.3%), or were taking low doses of GC (43.7%) at the last follow-up. Four patients had stopped GC within 6 months. No serious side effects were recorded. After persistent remission, a maintenance immunosuppressive therapy was then administered. Only 3 relapses in 3 different cases were recorded, all of them during drug-free remission in long-term follow-up. Reinduction was again effective in all.

Conclusion:

Anti-HMGCR myopathy is a rare and serious myopathy which usually affects older people during statin treatment. After statin suspension, a rapid and sustained remission can be achieved by induction with a triple aggressive therapy consisting in medium-to high doses of GC, high-dose IVIG, and MTX (3). GC should be tapered as soon as possible. Relapse appears infrequent during maintenance treatment. Monitoring anti-HMGCR antibody titer may be clinically relevant.

References:

[1]AL Mammen et al. N Engl J Med. 2016;374:664-9

[2]Musset L et al. Autoimmun Rev. 2016;15:983-93.

[3]Aggarwal A et al. Scand J Rheumatol. 2019; 1-7.

Acknowledgments:

We thank MD Francesca Grosso and MD Valentina Mecheri from the University of Florence, MD Angela Zuppa and MD Chiara De Michelis, from San Martino Hospital, Genova, for their valued collaboration in data collection

Disclosure of Interests:

Elena Treppo: None declared, Maria Infantino: None declared, Maurizio Benucci: None declared, Viviana Ravagnani: None declared, Boaz Palterer: None declared, Marina Grandis: None declared, Martina Fabris: None declared, Paola Tomietto: None declared, Mariangela Manfredi: None declared, Arianna Sonaglia: None declared, Maria Grazia Giudizi: None declared, Francesca Ligobbi: None declared, Daniele Cammelli: None declared, Paola Parronchi: None declared, Salvatore De Vita Consultant of: Roche, GSK, Speakers bureau: Roche, GSK, Novartis, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer