Mycophenolate mofetil may be an alternative for maintenance therapy of Behçet syndrome uveitis: a single-center retrospective analysis

Experience with mycophenolate in uveitis due to Behçet syndrome (BS) is limited. Twelve patients with panuveitis or posterior uveitis who were started mycophenolate were included. Data on demographic characteristics, therapies, ocular attacks, and adverse events were extracted from patient charts. Seven patients with BS uveitis were prescribed mycophenolate for remission induction, of which 6 were refractory/intolerant to conventional immunosuppressives. Mycophenolate was combined with anti-TNFs in 3 patients, resulting in no further ocular attacks. Mycophenolate had to be stopped in the fourth patient due to adverse events. The remaining 3 patients continued to have ocular attacks and were switched to other agents without any drop in visual acuity. Among the 5 patients who were prescribed mycophenolate for maintenance, 2 were relapse free, but 3 experienced ocular attacks. One patient had an exacerbation of mucocutaneous lesions, and 2 experienced adverse events. Mycophenolate monotherapy may not be adequate for remission induction of refractory BS uveitis, but it can be a safe and effective alternative when combined with a biologic agent. It may also be an option for maintenance therapy.

Pulmonary Hypertension Due to High-Output Heart Failure: Hereditary Hemorrhagic Telangiectasia

Pulmonary hypertension (PH) is a complex disorder that should be managed with a multidisciplinary approach. Although most of the underlying causes of left heart disease can be easily diagnosed with cardiac imaging, some pathologies might necessitate careful investigation to go beyond the obvious. High-output heart failure (HF) due to arteriovenous malformation (AVMs) is an unnoticeable cause for HF and PH. Patients with hepatic AVMs should always be carefully evaluated with regard to hereditary hemorrhagic telangiectasia (HHT) since they can have multiple signs related to the other systems without any symptoms. In this case report, we discussed a patient who was initially diagnosed as PH associated with HF with preserved ejection fraction but eventually was found to have PH associated with high-output HF due to hereditary hemorrhagic telangiectasia (HHT, or Osler Weber Rendu syndrome) after detailed evaluation.

Rituximab in the management of retroperitoneal fibrosis: A single tertiary rheumatology care center experience

AIM

To investigate the clinical and radiological outcomes and glucocorticoid-sparing effect of rituximab therapy in 13 patients with retroperitoneal fibrosis (RPF).

METHODS

We analyzed the data of both glucocorticoid-naive and glucocorticoid-resistant RPF patients who were treated with rituximab. Demographic features, positron emission tomography computed tomography (PET-CT) findings, and clinical and histopathologic outcomes were collected retrospectively.

RESULTS

We evaluated the data of 13 RPF patients (8M/5F). The median follow-up duration was 28 months (interquartile range [IQR] 24.5-55.5 months) and median age at the time of diagnosis was 50.8 years (IQR 46.5-54.5 years). PET-CT scans showed that following the rituximab therapy, the craniocaudal diameter of the RPF mass reduced from 74 mm (IQR 50.5-130 mm) to 52 mm (IQR 35-77 mm; p = .06), and periaortic thickness of the RPF mass reduced from 14 mm (5.5-21.9 mm) to 7 mm (4.5-11 mm; p = .12). The maximum standardized uptake value (based on body weight) of the RPF mass decreased from 5.8 (4.3-9.7) to 3.1 (2.8-5.3) after the therapy (p = .03). The number of patients with hydronephrosis reduced from 11 to 6 following rituximab therapy (p = .04). Before rituximab, nine patients received a median dose of 10 mg (IQR 0-27.5 mg) prednisolone per day. After the rituximab treatment, we discontinued prednisolone treatment for four out of nine patients and reduced the daily dose for the remaining patients. At the time of the final evaluation of the patients, the median prescribed prednisolone dose was 5 mg/day (IQR 2.5-7.5 mg/day; p = .01).

CONCLUSION

Our study shows that rituximab may be a favorable treatment option for glucocorticoid-refractory RPF patients with high disease activity on PET-CT scans.

AB1308 MYCOPHENOLATE FOR THE TREATMENT OF EYE INVOLVEMENT IN PATIENTS WITH BEHÇET’S SYNDROME

Background

Experience with mycophenolate in uveitis associated with Behçet’s syndrome (BS) is limited.

Objectives

We aimed to report the efficacy and safety of mycophenolate mofetil (MMF) and mycophenolate sodium (MPA) in the treatment of BS uveitis.

Methods

All patients with panuveitis or posterior uveitis who used mycophenolate for eye involvement between 2016 and 2018 were included. Patient charts were reviewed and data on demographic features, previous immunosuppressives, concomitant therapies, ocular attacks and outcome, and adverse events were extracted. Follow up was ended on October 2021.

Results

We included 12 BS patients (M/W: 8/4, mean age: 35±7 years) treated with mycophenolate during a mean follow-up of 42±19 months (Table 1). All but 3 patients had bilateral eye involvement. IFX and INF-α had been discontinued due to adverse events in all patients, AZA in 10/12, and Cy-A in 7/10.

Table 1.

Demographic, treatment and outcome of the 12 patients

Age /genderPrevious therapiesRemission induction or Maintenance therapyConcomitant biologicTime to ocular attack (months)Treatment after ocular attackAt the end of the follow-upMMF duration (months)25/MAZA,Cy-ARemission inductionNone2ADA was addedADA and MPAa were switched to INF due to further ocular attacks3842/WAZA,Cy-A, INF, IFXRemission inductionIFXN/AN/AStill on IFX and MMF7237/MAZA,Cy-A, INF, IFX, ADARemission inductionADAN/AN/AStill on ADA and MMF2732/MAZARemission inductionNone12IFX was addedStill on IFX and MMF5233/WAZA, Cy-A, INF, ADA, IFXRemission inductionNoneN/AN/AMPAb was switched to certolizumab and MTX524/MAZARemission inductionIFXN/AN/AStill on MMF and IFX was stopped due to remission6337/MAZA, Cy-ARemission inductionNone6IFX was addedIFX and MMF were switched to INF due to further ocular attacks4136/WAZA,Cy-A, INFMaintenanceNone2ADA was addedStill on ADA and MMF5036/MAZA,Cy-A, INF, IFXMaintenanceIFXN/AN/AStill on IFX and MMF was stopped due to remission1749/WAZA,Cy-A, INFMaintenanceNoneN/AN/AStill on MMF3937/MAZA, INFMaintenanceNone31Cy-A was addedStill on MMF and Cy-A38 d31/MAZA, Cy-A, INFMaintenanceNone5IFX was addedOff treatment for 2 years38

a MMF was switched to MPA due to numbness in hands and feet, and MPA was stopped due to arthralgia.

b MMF was switched to MPA due to diarrhea

Seven patients were prescribed mycophenolate for remission induction. One of these patients had had his first uveitis attack while on AZA treatment due to gastrointestinal involvement. The remaining 6 patients were using other immunosuppressives and experienced relapses that led to mycophenolate use. MMF was added to a biologic agent in 2 patients (IFX and ADA) and was initiated in combination with IFX in 1 patient. These 3 patients did not experience further ocular attacks and IFX was stopped due to remission in 1 patient. In the fourth patient, MMF was switched to MPA due to numbness in hands and feet and MPA was stopped due to arthralgia. This patient did not experience ocular attacks during 5 months of MPA therapy. The remaining 3 patients had further uveitis attacks without decrease in visual acuity 2, 6, and 12 months after MMF initiation, and IFX was added in 2 patients, and ADA in 1 patient. Two of these patients were switched to INF-α due to uveitis relapses. MMF was switched to MPA for diarrhea in 1 patient.

Five patients had received MMF for maintenance. One of these was using IFX when MMF was started and these 2 agents were used together. This patient discontinued MMF due to remission 17 months after MMF initiation and is still on IFX monotherapy. The second patient is still on MMF for 39 months without further ocular attacks. ADA, IFX and Cy-A were added in the remaining 3 patients due to ocular attacks 2, 5 and 31 months after MMF initiation. One of these 3 patients stopped IFX and MMF due to remission and is off treatment for 2 years.

Conclusion

Mycophenolate may be an alternative treatment modality in addition to biologics for patients with eye involvement who are intolerant to conventional therapies. Further data is needed to show whether it would be effective when used alone.

Disclosure of Interests

Didar Ucar: None declared, Yilmaz Ozyazgan: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Emir Cerme: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Melike Melikoglu: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

Haemophagocytic lymphohistiocytosis in a patient with familial Mediterranean fever and miliary tuberculosis: a case report

Haemophagocytic lymphohistiocytosis (HLH) is a lethal complication of several infections, especially viral origin. Mycobacterium tuberculosis infection can also lead to HLH, yet it is an uncommon trigger. Considering the role of increased cytokines in HLH, autoinflammatory conditions, such as familial Mediterranean fever (FMF), might contribute to its development. Nevertheless, the possible relationship between FMF and HLH has been suggested only in some case reports. We present a case of FMF who admitted to the hospital with consitutional symptoms and chest pain regarding to recurrent pericarditis. On a blood test, pancytopenia and elevated acute phase reactants were seen. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography demonstrated positive FDG uptake sites on both the right and left surrenal glands, the visceral layer of pericard, and reactive lymphadenomegalies at multiple mediastinal regions. Bone marrow biopsy revealed haemophagocytosis. Methylprednisolone treatment was initiated. Despite immunosuppressive treatment, clinical and biochemical parameters deteriorated; thus, a thorax computed tomography was executed. Findings were consistent with miliary tuberculosis infection. M. tuberculosis was detected in blood culture and bronchoalveolar lavage culture material. Also, bone marrow and surrenal biopsy material revealed necrotising caseating granuloma.

SAT0534 RITUXIMAB FOR REFRACTORY IDIOPATHIC RETROPERITONEAL FIBROSIS: A SINGLE TERTIARY CENTER EXPERIENCE

Background:

Idiopathic retroperitoneal fibrosis (RPF) is a progressive disorder of the retroperitoneum which is often idiopathic. Although prednisolone is the mainstay approach to treating RPF, the remission rates range between 75% to 95% (1-2).

Objectives:

Here, we report the outcomes and steroid-sparing effect of Rituximab (Rtx) therapy in 14 patients with RPF.

Methods:

This retrospective study was conducted at a tertiary rheumatology center. Patients were diagnosed with RPF and had at least a course of 0.5-1 mg/kg prednisolone treatment previously. These patients were switched to Rtx due to inadequate response or side effects while on prednisone, tamoxifen, azathioprine or cyclophosphamide therapy. Patients were treated with Rtx in order to be included in this study. Involvement and activation of RPF was shown via PET-CT either before or at least 6 months after the therapy. Daily prednisolone dose was noted before rituximab initiation and 6 months after the therapy. All of the patients reported, except two, were followed for at least 6 months after the Rtx treatment. The final disease status of the three patients were not included in the study.

Results:

Fourteen patients (7F) received at least 2 cycles (1 gr for each) of Rtx. The age of diagnosis was 54.3 ± 11.0 years, follow-up duration was 46.0 ± 37.2 months. The previous treatments, number of the cycles of Rtx and final disease status were shown in the Table. The Control PET-CT revealed metabolic and radiologic remission in 3 patients. In 6 patients, the disease remained stable. In 2 patients there was disease progression hence they were treated with the second course of Rtx. One of the two patients had the progression two years after the first cycle but then, was lost to follow-up. The mean prednisolone dose decreased from 15.5 ± 12.4 mg to 2.2 ± 2.2 mg/day after 6 months of Rtx initiation. Final prednisolone dose was 2.6 ± 5.5 mg/day (Figure). Rtx treatment was ceased in 6 patients with sustained remission.

Conclusion:

The present study shows that Rtx could be a therapeutic option after gluocorticoid or DMARD failure. The steroid sparing effect of Rtx is essential and further prospective studies are needed to assess the Rtx efficacy more objectively in RPF treatment.

Table.

Characteristics and final disease status of the patients

NumberAge of Rituximab InitiationSexPrevious TreatmentsNumber of Rituximab Cycle(s)Final Pet-CT149MPred, Mtx1Stable disease254MPred,Mtx1Stable disease346FPred,Aza,Tmx,Mmf2Progression440MPred,Aza,Mtx4Remission563FPred,Tmx10Stable disease647FPred,Mtx2Stable disease730FPred1Stable disease852MPred,Aza2Progression954MPred1N/A1059MPred,Aza,Mtx1N/A1130FPred, Mtx6Remission1240FPred,Aza,Tmx;Cyc3Stable disease1350MPred2N/A1445FPred,Aza3Remission

Pred:Prednisolone, Aza:Azathioprine, Tmx:Tamoxifen,Mtx:Methotrexate,Cyc:cyclophosphamide

References:

[1]Vaglio A, Palmisano A, Alberici F, Maggiore U, Ferretti S, Cobelli R, Ferrozzi F, Corradi D, Salvarani C, Buzio C: Prednisone versus ta- moxifen in patients with idiopathic retroperitoneal fibrosis: an open-label randomised controlled trial. Lancet 378: 338–346, 2011

[2]van Bommel EF, Siemes C, Hak LE, van der Veer SJ, Hendriksz TR: Long-term renal and patient outcome in idiopathic retroperito- neal fibrosis treated with prednisone. Am J Kidney Dis 49: 615–625, 2007

Disclosure of Interests:

None declared