Cyclophosphamide vs rituximab for eradicating inhibitors in acquired hemophilia A: A randomized trial in 108 patients

BACKGROUND

Acquired hemophilia A (AHA) is a rare autoimmune disorder due to autoantibodies against Factor VIII, with a high mortality risk. Treatments aim to control bleeding and eradicate antibodies by immunosuppression. International recommendations rely on registers and international expert panels.

METHODS

CREHA, an open-label randomized trial, compared the efficacy and safety of cyclophosphamide and rituximab in association with steroids in patients with newly diagnosed AHA. Participants were treated with 1 mg/kg prednisone daily and randomly assigned to receive either 1.5-2 mg/kg/day cyclophosphamide orally for 6 weeks, or 375 mg/m2 rituximab once weekly for 4 weeks. The primary endpoint was complete remission over 18 months. Secondary endpoints included time to achieve complete remission, relapse occurrence, mortality, infections and bleeding, and severe adverse events.

RESULTS

Recruitment was interrupted because of new treatment recommendations after 108 patients included (58 cyclophosphamide, 50 rituximab). After 18 months, 39 cyclophosphamide patients (67.2 %) and 31 rituximab patients (62.0 %) were in complete remission (OR 1.26; 95 % CI, 0.57 to 2.78). In the poor prognosis group (FVIII < 1 IU/dL, inhibitor titer > 20 BU mL-1), significantly more remissions were observed with cyclophosphamide (22 patients, 78.6 %) than with rituximab (12 patients, 48.0 %; p = 0.02). Relapse rates, deaths, severe infections, and bleeding were similar in the 2 groups. In patients with severe infection, cumulative doses of steroids were significantly higher than in patients without infection (p = 0.03).

CONCLUSION

Cyclophosphamide and rituximab showed similar efficacy and safety. As first line, cyclophosphamide seems preferable, especially in poor prognosis patients, as administered orally and less expensive.

FUNDING

French Ministry of Health.

CLINICALTRIALS

gov number: NCT01808911.

Recurrent (or episodic) fever of unknown origin (FUO) as a variant subgroup of classical FUO: a French Multicenter Retrospective study of 170 patients

BACKGROUND

Recurrent-FUO (fever of unknown origin) is a rare subtype of FUO for which diagnostic procedures are ill-defined and outcome data are lacking.

METHODS

We performed a retrospective multicentre study of patients with recurrent-FUO between 1995 and 2018. By multivariate analysis, we identified epidemiological, clinical, and prognostic variables independently associated with final diagnosis and mortality.

RESULTS

Of 170 patients, 74 (44%) had a final diagnosis. Being ≥ 65 years of age (OR=5.2; p<0.001), contributory history (OR=10.4; p < 0.001), and abnormal clinical examination (OR=4.0; p=0.015) independently increased the likelihood of reaching a diagnosis, whereas lymph node and/or spleen enlargement decreased it (OR = 0.2; p=0.004). The overall prognosis was good; 58% of patients recovered (70% of those with a diagnosis). Twelve (7%) patients died; patients without a diagnosis had a fatality rate of 2%. Being ≥ 65 years of age (OR = 41.3; p < 0.001) and presence of skin signs (OR = 9.5; p = 0.005) significantly increased the risk of death.

CONCLUSION

This study extends the known yield of recurrent-FUO and highlights the importance of repeated complete clinical examinations to discover potential diagnostic clues during follow- up. Moreover, their overall prognosis is excellent.

[Neurological forms of long COVID in adults: Critical approach]

Now recognized by health authorities, long COVID is identified as a frequent condition complicating the evolution of SARS-CoV-2 infection. Its polymorphic and sometimes disconcerting clinical expression raises questions about its mechanism. Patterns of clinical expression suggest extensive involvement of the nervous system through an almost ubiquitous cognitive complaint. This article reviews the neurological symptoms and forms of these patients, and the neuropsychological explorations aimed at objectifying a cognitive deficit. The studies published until now confronted with the clinical mode of expression, did not make it possible to define a deficit neuropsychological profile at the level of the groups, and evoked more a functional impairment than a lesion. However, each series mentions a small number of patients in whom a cognitive deficit is objectified. The uncertainties about the causes of the prolonged forms of COVID, the heterogeneity of the published studies, and the virtual absence of temporal evolution data should make one cautious about the interpretation of these data but should in no way delay or prevent taking into account care of these patients.

Infectious risk when prescribing rituximab in patients with hypogammaglobulinemia acquired in the setting of autoimmune diseases

We conducted a single-centre retrospective cohort study in a French University Hospital between 2010 and 2018 to describe the risk of severe infectious event (SIE) within 2 years after the date of first rituximab infusion (T0) prescribed after the evidence of acquired hypogammaglobulinemia (gamma globulins [GG] ≤ 6 g/L) in the setting of autoimmune diseases (AID) other than rheumatoid arthritis. SIE occurred in 26 out of 121 included patients. Two years cumulative incidence rates were 12.7 % (95 % CI 5.1-23.9) in the multiple sclerosis/neuromyelitis optica spectrum disorder group (n = 48), 27.6 % (95 % CI 15.7-40.9) in the ANCA-associated vasculitis group (n = 48) and 30.6 % (95 % CI 13.1-50.3) in the 'other AID' group (n = 25). Median GG level at T0 was 5.3 g/l (IQR 4.1-5.6) in the 'SIE' group and 5.6 g/l (IQR 4.7-5.8) in the 'no SIE' group (p = 0.04). In regression analysis, risk of SIE increased with Charlson comorbidity index ≥ 3 (OR 2.77; 95 % CI 1.01-7.57), lung disease (OR 3.20; 95 % CI 1.27-7.99), GG < 4 g/L (OR 3.39; 95 % CI 1.02-11.19), concomitant corticosteroid therapy (OR 4.13; 95 % CI 1.63-10.44), previous cyclophosphamide exposure (OR 2.69; 95 % CI 1.10-6.61), a lymphocyte count < 1000 cells/µL (OR 2.86; 95 % CI 1.12-7.21) and absence of pneumococcal vaccination (OR 3.50; 95 % CI 1.41-8.70). These results may help to inform clinical decision when considering a treatment by rituximab in immunosuppressed AID patients with hypogammaglobulinemia.

French practical guidelines for the diagnosis and management of relapsing polychondritis

Relapsing polychondritis is a rare systemic disease. It usually begins in middle-aged individuals. This diagnosis is mainly suggested in the presence of chondritis, i.e. inflammatory flares on the cartilage, in particular of the ears, nose or respiratory tract, and more rarely in the presence of other manifestations. The formal diagnosis of relapsing polychondritis cannot be established with certainty before the onset of chondritis, which can sometimes occur several years after the first signs. No laboratory test is specific of relapsing polychondritis, the diagnosis is usually based on clinical evidence and the elimination of differential diagnoses. Relapsing polychondritis is a long-lasting and often unpredictable disease, evolving in the form of relapses interspersed with periods of remission that can be very prolonged. Its management is not codified and depends on the nature of the patient's symptoms and association or not with myelodysplasia/vacuoles, E1 enzyme, X linked, autoinflammatory, somatic (VEXAS). Some minor forms can be treated with non-steroidal anti-inflammatory drugs, or a short course of corticosteroids with possibly a background treatment of colchicine. However, the treatment strategy is often based on the lowest possible dosage of corticosteroids combined with background treatment with conventional immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil, rarely cyclophosphamide) or targeted therapies. Specific strategies are required if relapsing polychondritis is associated with myelodysplasia/VEXAS. Forms limited to the cartilage of the nose or ears have a good prognosis. Involvement of the cartilage of the respiratory tract, cardiovascular involvement, and association with myelodysplasia/VEXAS (more frequent in men over 50years of age) are detrimental to the prognosis of the disease.

Prognostic factors in giant cell arteritis associated aortitis with PET/CT and CT angiography at diagnosis

BACKGROUND

Prognosis data on giant-cell arteritis (GCA)-associated aortitis are scarce and heterogeneous. The aim of this study was to compare the relapses of patients with GCA-associated aortitis according to the presence of aortitis on CT-angiography (CTA) and/or on FDG-PET/CT.

METHODS

This multicenter study included GCA patients with aortitis at diagnosis; each case underwent both CTA and FDG-PET/CT at diagnosis. A centralized review of image was performed and identified patients with both CTA and FDG-PET/CT positive for aortitis (Ao-CTA+/PET+); patients with positive FDG-PET/CT but negative CTA for aortitis (Ao-CTA-/PET+), and patients solely positive on CTA.

RESULTS

Eighty-two patients were included with 62 (77%) of female sex. Mean age was 67±8 years; 64 patients (78%) were in the Ao-CTA+/PET+ group; 17 (22%) in the Ao-CTA-/PET+ group and 1 had aortitis only on CTA. Overall, 51 (62%) patients had at least one relapse during follow-up: 45/64 (70%) in the Ao-CTA+/PET+ group and 5/17 (29%) in the Ao-CTA-/PET+ group (log rank, p = 0.019). In multivariate analysis, aortitis on CTA (Hazard Ratio 2.90, p = 0.03) was associated with an increased risk of relapse.

CONCLUSION

Positivity of both CTA and FDG-PET/CT for GCA-related aortitis was associated with an increased risk of relapse. Aortic wall thickening on CTA was a risk factor of relapse compared with isolated aortic wall FDG uptake.

Glucocorticoids selectively affect the memory T cell response to SARS-Cov2 spike in vaccinated and post-infected patients with systemic lupus erythematosus

Immune response to vaccines and pathogens remains unclear in patients with systemic lupus erythematosus (SLE). To investigate this, a single-center retrospective study was conducted with 47 SLE patients vaccinated against COVID-19, including 13 who subsequently developed an asymptomatic/mild disease. As compared to controls, post-vaccine response against Spike was reduced in SLE patients when considering both memory T-cells in a whole blood interferon gamma release assay (IGRA-S) and IgG anti-Spike antibody (Ab) responses. The SLE-associated defective IGRA-S response was associated with a serum albumin level below 40 g/L and with the use of glucocorticoids, while a defective IgG anti-Spike Ab response was associated with lower levels of anti-dsDNA and anti-SSA/Ro 52 kDa Abs. IGRA-S and IgG anti-Spike responses were independent from SLE activity and clinical phenotype, low complement, hypergammaglobulinemia, and lymphopenia. As compared to controls, SLE patients showed a rapid decay of anti-Spike T-cell memory and stable IgG anti-Spike Ab responses. In conclusion, both T cell and humoral anti-Spike responses were independently affected in our SLE patients cohort, which supports the exploration of both responses in the follow-up of SLE patients and especially in those receiving glucocorticoids.

Immunological and translational key challenges in systemic lupus erythematosus: A symposium update

The first LBMR-Tim (Toulouse Referral Medical Laboratory of Immunology) symposium convened on December 16, 2022 in Toulouse, France to address challenging questions in systemic lupus erythematosus (SLE). Special focus was put on (i) the role played by genes, sex, TLR7, and platelets on SLE pathophysiology; (ii) autoantibodies, urinary proteins, and thrombocytopenia contribution at the time of diagnosis and during follow-up; (iii) neuropsychiatric involvement, vaccine response in the COVID-19 era, and lupus nephritis management at the clinical frontline; and (iv) therapeutic perspectives in patients with lupus nephritis and the unexpected adventure of the Lupuzor/P140 peptide. The multidisciplinary panel of experts further supports the concept that a global approach including basic sciences, translational research, clinical expertise, and therapeutic development have to be prioritized in order to better understand and then improve the management of this complex syndrome.

Long-term prophylaxis in hereditary angioedema management: Current practices in France and unmet needs

Background: Hereditary angioedema (HAE) is characterized by unpredictable and potentially life-threatening attacks of cutaneous and submucosal swelling. Over the past decade, new agents, based on a better understanding of the underlying biologic mechanisms of HAE, have changed the face of long-term prophylaxis (LTP). Objective: The objective was to describe current practices and unmet needs with regard to LTP for HAE in expert centers in France. Methods: The study was conducted in France in 2020. Based on their experience with patients with HAE who had visited their center at least once in the past 3 years, physicians from 25 centers who are expert in the management of HAE were requested to fill in a questionnaire that encapsulated their active patient list, criteria for prescribing LTP, and medications used. They were asked about potential unmet needs with currently available therapies. They were asked to express their expectations with regard to the future of HAE management. Results: Analysis was restricted to 20 centers that had an active patient file and agreed to participate. There were 714 patients with C1 inhibitor (C1-INH) deficiency, of whom 423 (59.2%) were treated with LTP. Altered quality of life triggered the decision to start LTP, as did the frequency and severity of attacks. Ongoing LTP included androgens (28.4%), progestins (25.8%), lanadelumab (25.3%), tranexamic acid (14.2%), intravenous C1-INHs (5.6%), and recombinant C1-INH (0.7%). Twenty-nine percent of the patents with LTP were considered to still have unmet needs. Physicians' concerns varied among therapies: poor tolerability for androgens and progestins, a lack of efficacy for tranexamic acid and progestins, dosage form, and high costs for C1-INHs and lanadelumab. Physicians' expectations encompassed more-efficacious and better-tolerated medications, easier treatment administration for the sake of improved quality of life of patients, and less-expensive therapies. Conclusion: Despite the recent enrichment of the therapeutic armamentarium for LTP, physicians still expressed unmet needs with currently available therapies.

Aseptic Abscess Syndrome: Clinical Characteristics, Associated Diseases, and up to 30 Years’ Evolution Data on a 71-Patient Series

Aseptic abscess (AA) syndrome is a rare type of inflammatory disorder involving polymorphonuclear neutrophils (PMNs), often associated with inflammatory bowel disease (IBD). This study sought to describe the clinical characteristics and evolution of this syndrome in a large cohort. We included all patients included in the French AA syndrome register from 1999 to 2020. All patients fulfilled the criteria outlined by André et al. in 2007. Seventy-one patients were included, 37 of which were men (52.1%), of a mean age of 34.5 ± 17 years. The abscesses were located in the spleen (71.8%), lymph nodes (50.7%), skin (29.5%), liver (28.1%), lung (22.5), and rarer locations (brain, genitals, kidneys, ENT, muscles, or breasts). Of all the patients, 59% presented with an associated disease, primarily IBD (42%). They were treated with colchicine (28.1%), corticosteroids (85.9%), immunosuppressants (61.9%), and biologics (32.3%). A relapse was observed in 62% of cases, mostly in the same organ. Upon multivariate analysis, factors associated with the risk of relapse were: prescription of colchicine (HR 0.52; 95% CI [0.28–0.97]; p = 0.042), associated IBD (HR 0.57; 95% CI [0.32–0.99]; p = 0.047), and hepatic or skin abscesses at diagnosis (HR 2.14; 95% CI [1.35–3.40]; p = 0.001 and HR 1.78; 95% CI [1.07–2.93]; p = 0.024, respectively). No deaths occurred related to this disease. This large retrospective cohort study with long follow up showed that AA syndrome is a relapsing systemic disease that can evolve on its own or be the precursor of an underlying disease, such as IBD. Of all the available treatments, colchicine appeared to be protective against relapse.

Clinical impact and prognosis of cryoglobulinemia and cryofibrinogenemia in systemic sclerosis

INTRODUCTION

An association of systemic sclerosis (SSc) with cryoglobulin and/or cryofibrinogenemia has been described. However, clinical, biological, morphological and prognostic implications are unknown. The objective of this study was to describe the phenotype and evaluate the prognosis of cryoglobulinemia and/or cryofibrinogenemia in the progression of SSc.

MATERIALS AND METHODS

Patients were included from the Systemic Scleroderma Toulouse Cohort (SSTC), between June 1, 2005 and May 31, 2018, and underwent a measurement of a cryoglobulin and/or cryofibrinogen in immunology laboratory at the Toulouse University Hospital Center. Patients with and without cryoglobulinemia >50 mg/l and patients with and without cryofibrinogenemia were compared to identified the impact of cryoprcipitate on the phenotype. Mortality based on cryoprecipitate was explored.

RESULTS

166 patients were included in the study. 43.3% and 46.6% had a cryoglobulinemia >50 mg/l and cryofibrinogenemia, respectively. Cryoglobulin >50 mg was not associated with microvascular damage. Cryoglobulin does not influence the phenotype. 5-and 10-years survival were 97.6% and 88.8% respectively in patients with cryoglobulinemia >50 mg/l versus 91.9% and 78.4% in patients without cryoglobulin>50 mg/l. 10-years survival was better for patients with cryoglobulinemia >50 mg/l (log-rank 0.0363). Cryofibrinogenemia was not associated with neoplasia, any clinical (in particular ischemic damage), biological or morphological features. Cryofibrinogenemia had no influence on the mortality of these patients.

CONCLUSION

Cryoglobulinemia and cryofibrinogenemia are frequent in SSc. The presence of cryoprecipitate (cryoglobulin or cryofibrinogen) not influence the phenotype and has not associated with a poor survival.

AB0651 Clinical Impact and Prognosis of cryoglobulinemia and cryofibrinogenemia in Systemic Sclerosis

Background

Systemic sclerosis (SSc) is reported to be a secondary cause of cryoglobulinemia as well as cryofibrinogenemia. However, prevalence, clinical implication and associated pronostic of cryoprecipitates in SSc are unknown.

Objectives

To describe the prevalence, the phenotype and evaluate the prognosis of cryoglobulinemia and/or cryofibrinogenemia associated with systemic sclerosis.

Methods

We included all adult (≥18 years) consecutive SSc patients from the Systemic Scleroderma Toulouse Cohort (SSTC) [1] for whom a cryoglobulin and/or cryofibrinogen measurement was carried out at the immunology laboratory of the Toulouse University Hospital between June 1, 2005 and May 31, 2018 and at least one follow-up visit. We compared SSc-patients characteristics’ with and without cryoglobulinemia > 50 mg/l and with and without cryofibrinogenemia. Survival analysis based on presence of cryoglobulin cryofibrinogen was performed using the Kaplan-Meier method. Univariable and multivariable Cox proportional hazards models (ascending step-by-step method) were used to determine baseline variables associated with cryoglobulin or cryofibrinogen presence.

Results

166 patients were included in the study. 74.6% of patients were women, with a average age at diagnosis of 51.2 years-old. 24% were diffuse cutaneous subtypes and 71.6% limited cutaneous subtypes. Anti-centromere and anti-Scl70 were respectively positive in 44.5% and 21.6% of cases. All these patients were assessed for cryoglobulin detection and 75 cryofibrinogen detection in serum. 43.3% had a cryoglobulinemia >50 mg/l. 46.6% had cryofibrinogenemia. Patients with cryoglobulinemia >50 mg had more cardiac diastolic involvement (22.8% vs. 5.1% p=0.0395). In the multivariate analysis, diastolic involvement (HR=6.23; p=0.0331) was an independent predictor of cryoglobulin >50 mg/l. Survival at 10 years was better for patients with cryoglobulinemia >50 mg/l (log-rank 0.0363) (Figure 1). Survival at 5 and 10 years was 97.6% and 88.8% respectively in patients with cryoglobulinemia >50 mg/l versus 91.9% and 78.4% in patients with cryoglobulinemia <50 mg/l. In cox regression model adjusted for gender, age and type of systemic sclerosis, cryoglobulin >50 mg/l was negatively associated with mortality (HR: 0.09; p=0.03). The presence of cryofibrinogenemia was not associated with any clinical, biological or morphological features. In the multivariate analysis, no variable was predictive of the presence of cryofibrinogenemia in patients with SSc. The presence of cryofibrinogenemia had no influence on the mortality of these patients.

Conclusion

In SSc patients, the presence of cryoglobulin >50 mg/l is an independent predictive factor of cardiac diastolic involvement and is associated with a better survival. However, cryofibrinogenemia does not influence clinical phenotype or impact mortality in SSc patients.

References

[1]De Almeida Chaves S, Porel T, Mounié M, Alric L, Astudillo L et al. Sine scleroderma, limited cutaneous, and diffused cutaneous systemic sclerosis survival and predictors of mortality. Arthritis Res Ther. 2021 Dec 7;23(1):295. doi: 10.1186/s13075-021-02672-y.

Disclosure of Interests

None declared

AB0521 PERICARDITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS: CHARACTERISTICS, MANAGEMENT, EVOLUTION AND PREDICTIVE FACTORS FOR RELAPSE. A MONOCENTRIC RETROSPECTIVE STUDY

Background

Pericarditis is frequent in Systemic Lupus Erythematosus (SLE) and usually benign. Dedicated studies are scarce. However, recurrences can lead to repeated steroid prescriptions and further immunosuppression. The best management, including the potential benefit of colchicine, remains to be determined.

Objectives

The aim of this study was to describe management, evolution over time and risk factor for relapse in SLE pericarditis in our University Hospital Center.

Methods

Cases were retrospectively collected among hospital discharge data (coding code “SLE” and “pericarditis”), from January 1997 to December 2019. All SLE cases met the ACR/EULAR 2019 classification criteria. Pericarditis cases met ESC 2015 diagnosis criteria. Patients with conditions other than lupus known to cause pericarditis were excluded as well as patients with myocarditis. A minimal follow-up of one year after pericarditis diagnosis was mandatory. Relapse- free survival was described using an actuarial survival model.

Results

Among 103 patients identified in the database, 29 patients (women: n=25, mean age 30 +/- 13 years) were included. Median follow-up was 7 years [range: 1-22].

Description of first episodes: 31% (n= 9) were inaugural of SLE; otherwise, median time elapsed since SLE diagnosis was 65 months [1.7-400]. Fifty-five percent (n=16) of first episodes occurred during a multi-systemic lupus flare. Median SLEDAI-2K was 9 [range: 4-30|. Clinical symptoms and signs were typical chest pain (93%, n=27), dyspnea (55%, n=16); pericardial rub (31%, n=9), fever (38%, n=11). EKG was abnormal in 59% of the cases (n= 17). When present, 79% of effusions (n=17/22) were circumferential, 82% (n= 18/22) were mild to moderate (<20mm), and 25% (n=7) were dry pericarditis. Two Cardiovascular Magnetic Resonance imaging were performed and were pathological.

Biological data showed always high CRP levels (65mg [range: 7-460]), high-titer anti-DNA (79%, n=19) but few patients had low complement levels (C3 21% (n=4/19), C4 26%(n=5/19)).

Prescribed drugs were non-steroidal anti-inflammatory drugs/acetylsalicylic acid (NSAIDs/ASA) (41%, n=12), corticosteroids (66%, n=19; mean daily prednisone dose: 57.2mg +/- 13.9), colchicine 0.5 to 1mg/day (41%; n=12). There was a significant difference in SLEDAI-2K values at pericarditis onset between those treated with NSAIDs/ASA (7.5, [range: 0-16]) and those not (12, [range: 4-30]), (p<0.05). Only 41% (n=5) of colchicine prescriptions lasted at least 3 months; they were associated with a lower SLEDAI-2K at pericarditis onset compared to pericarditis not or insufficiently treated with colchicine (respectively, 7[range: 4-9] and 11[range: 4-30], p=0.04). Immunosuppressive drugs were prescribed in 17% (n=5) of the patients, always due to extra-pericardial involvements.

Recurrences were frequent (55%, 16 patients out of 29) and multiple (1 to 6, average 3 ± 1.26). Short and long-term relapse-free survival tended to be better in patients exposed to at least 3 months of colchicine (100% vs 75% at 1 year, p=0.09) (Figure 1). There was no statistical difference (p=0.25) in terms of short-term relapse-free survival in patients treated with NDAIDs/ASA compared to those who were not. Corticosteroid prescription and previous antimalarial treatment were not associated with a poorer or better outcome during the year following remission (p=0.78). No patient has progressed to constriction.

Figure 1.

Relapse-free survival at 12 months according to colchicine prescription

Conclusion

Our conclusions are limited due to the small number of patients and lack of multivariate analysis.

Further studies are necessary to confirm the potential benefit of colchicine to prevent incessant pericarditis or relapses in this population.

References

[1]Kruzliak P, et al. Acta Cardiol 2013;68:629–33.

Disclosure of Interests

None declared

AB1151 DOES PREDNISONE AFFECT COVID19 VACCINE T CELL RESPONSE? A STUDY OF VACCINE RESPONSE IN PATIENTS WITH IMMUNE SYSTEM DISEASES

Background

A whole blood interferon gamma release assay (IGRA) based on the stimulation of SARS-Cov2-specific memory T cells using purified and full-lenght Spike and Nucleocapsid recombinant proteins was developed, together with anti-Spike antibody detection.

Objectives

To study COVID19 vaccine cellular and humoral responses in patients with immune system diseases (ISD) and healthy controls.

Methods

Non-vaccinated healthy individuals (n=103), SARS-Cov-2 infected individuals (n=9), and 104 samples from individuals having received COVID19 vaccine including 28 non-sars-cov2 infected patients with ISD diseases were included. Preliminary experiments were initiated using different platforms (ELISpot, IGRA, recombinant proteins or peptides) in order to evaluate Spike T cell response in volunteers vaccinated with BNT162b2 showing a S2>S1 poly-epitopic response.

Results

Twenty-eight patients (25 women, 3 men; mean age 59.1(±17,8)) with various ISD were investigated. These patients suffered from lupus (n=14), vasculitis (n=4), myositis (n=2), sarcoidosis (n=2), primary immunodeficiency (n=3), Sjögren’s syndrome (n=2) and pericarditis (n=1). Three patients had received 4 doses, 16 three doses, and 8 two doses of vaccine (Pfizer: n=25; Moderna n=1, Astra-Zeneca n=1). One patient refused the vaccination. The tests were performed 86.7 (±60.5) days after last vaccine dose. Ten patients were on prednisone (mean dose: 11,8 mg, median 7.5 mg, range: 5-40). Among those patients, 6 had only prednisone, 1 was also treated with belimumab, 3 with methotrexate (MTX) and 1 with azathioprine (AZA).

Following COVID19 vaccination, humoral (100% in healthy vs 84.6% in ISD patients) and IGRA-Spike T cell (96% in healthy vs 59.7% in AI patients) responses took place with lower response reported among the ISD disease group (Figure 1). Humoral and cellular COVID19 vaccine responses significantly decrease after 100 days post vaccine.

Figure 1.

SARS-Cov2 humoral and T cell responses in non-vaccinated healthy individuals (n=103), SARS-Cov-2 infected individuals (n=9), and 104 samples from individuals having received COVID19 vaccine including 28 non-Sars-cov2 infected patients with ISD diseases. A- Anti-SARS-Cov2 Spike total IgM/IgG/IgA antibody (Ab) titers (BAU/mL) tested by ELISA. B- Whole blood IFN-γ release assay (IGRA) response to the full-length Spike recombinant protein (IGRA-Spike). C- Whole blood IGRA response to the nucleocapsid recombinant protein (IGRA-Nuc). Positivity cut-off (dot line) p values <0.05 are indicated when significant (ANOVA).

5/5 vaccinated patients on CS alone, 2/5 vaccinated patients on corticosteroids with MTX/AZA/Belimumab and 3/17 other vaccinated patients (all being primary immunodeficiency patients) had no cellular response. Humoral and T cell responses were independent from sex and age.

Conclusion

Altogether, this ongoing study confirms the utility of the IGRA-Spike/-nucleocapsid assay coupled with serology in COVID19 vaccinated individuals and in particular in ISD patients treated with steroids, who may be at risk when the humoral protection decreases.

References

none

Disclosure of Interests

None declared

POS1178 PRESCRIBING RITUXIMAB IN PATIENTS WITH AUTO-IMMUNE DISEASES AND ACQUIRED HYPOGAMMAGLOBULINEMIA: DESCRIPTION OF THE RISK OF SEVERE INFECTION IN 121 PATIENTS BEFORE THE SARS-Cov2 ERA

Background

Rituximab (RTX) induces rapid, usually complete and prolonged depletion of circulating B cells, and also hypogammaglobulinemia in some patients. There are limited data regarding the risk of severe infection events (SIE) when initiating or continuing rituximab in patients with acquired hypogammaglobulinemia, especially in patients suffering from autoimmune diseases (ADs) other than rheumatoid arthritis (RA) (1).

Objectives

To describe the risk of severe infectious events (SIE) following initiation (rituximab-naïve patients [RNP]) or continuation of RTX therapy (rituximab-continuing patients [RCP]) in patients suffering from severe ADs other than RA and acquired hypogammaglobulinemia.

Methods

We conducted a single-center retrospective cohort study at the University Hospital of Toulouse (France) between 2010 and 2018. Patients were included if they had received at least one dose of RTX in the year following the evidence of hypogammaglobulinemia (defined as gammaglobulins [GG]≤ 6g/L on serum protein electrophoresis) in the setting of ADs other than RA. The primary outcome was the occurrence of a SIE within 2 years after the date of first RTX infusion (T0) prescribed after the evidence of hypogammaglobulinemia. SIE were infections either fatal or requiring hospitalization.

Results

We included 121 patients (37 RNP and 84 RCP): 48 had ANCA-associated vasculitis (AAV), 48 multiple sclerosis (MS, n=41) or neuromyelitis optica (NMO, n=7), and 21 another severe AD. RTX was prescribed as induction therapy in 39 patients and as maintenance therapy in 82; 112/121 patients were followed for 2 years. Mean GG level were 5.5 g/L (IQ25-75 4.6-5.7) at T0, 5.5 g/L (IQ25-75 5-6.4) at one year, 5.7g/L (IQ25-75 4.8-6.1) at two years and 8 patients had a decrease of their GG level below 4g/L. Ten patients received immunoglobulin replacement therapy (IGRT) mostly after infection (n=6).

Twenty-six patients (23.2%) had at least one SIE during follow-up: 12.8 % in the MS/NMO group with a 2-year incidence at 6.9 (3.1-15.3) per 100 person-years, 29.5 % in the AAV group with a 2-year incidence at 18.3 (9.3-20.1) per 100 person-years, 33.3 % in the ‘other ADs’ group with a 2-year incidence at 22.2 (10.6-46.5) per 100 person-years. Infection was opportunistic in 8 patients (33.3%) and 4 died from SIE.

Risk factors of SIE at T0 were male gender (61.5% vs. 39.5% p<0.05), lung disease (65.4% vs. 37.2% p=0.01), renal failure (59.1% vs. 28.6% p=0.01), a higher Charlson comorbidity index (p=0.001), a previous treatment by cyclophosphamide (53.8% vs. 30.2%; p=0.03), ≥ 5 mg/d prednisone (69.2% vs. 33.7%, p=0.003), lack of pneumococcal vaccination (61.5% vs 31.4%, p=0.01). GG level was 5.3 g/l [4.1-5.6] in the ‘SIE’ group vs 5.6 g/l [4.8-5.8] in the ‘no SIE’ group (p=0.04). Incidence of SIE was 46% and 20.2% among patients with GG< 4 g/L or GG≥ 4 g/L, respectively (p=0.07). No multivariable analysis provided reliable results.

Conclusion

Our study provides useful information for clinicians considering initiating or continuing rituximab therapy in patients with acquired hypogammaglobulinemia before Sars-Cov2 era. Prospective studies are necessary to improve the knowledge on outcome of patients treated by rituximab despite low immunoglobulins levels. Prophylactic IGRT may be appropriate in higher risk patients, especially if the GG level is below 4 G/L.

References

[1]Boleto G et al. Predictors of hypogammaglobulinemia during rituximab maintenance therapy in rheumatoid arthritis: A 12-year longitudinal multi-center study. Seminars in Arthritis and Rheumatism. oct 2018;48(2):149‑54.

Figure 1.

Two years probability of survival without serious infectious event according to pathology group (112 patients included)

Disclosure of Interests

None declared

POS0884 DESCRIPTIVE EPIDEMIOLOGY OF SEVERE CARDIAC INVOLVEMENT IN SYSTEMIC SCLEROSIS: A BICENTRIC RETROSPECTIVE STUDY ON 459 PATIENTS

Background

The prevalence of cardiac involvement in systemic sclerosis (SSc) varies in the literature between 3% and 44% and represents a leading cause of mortality in this disease. The incidence of severe cardiac involvement and the factors associated with the occurrence of severe cardiac involvement are not known in the literature.

Objectives

The objective of this study was to evaluate the incidence, prognosis and factors associated with the occurrence of severe cardiac involvement during SSc course.

Methods

We conducted a retrospective, bi-centric study from January 1, 1966 to December 31, 2018. The patients included had a diagnosis of SS according to the ACR/EULAR 2013 criteria. The primary endpoint was the occurrence of severe cardiac involvement. Cardiac involvement was defined by the presence of at least one of the following elements: death of cardiovascular origin, left ventricular ejection fraction less than or equal to 50%, abnormality of at least 3 measurement parameters of diastolic function, global longitudinal strain less than or equal to 18 in absolute value, ventricular tachycardia, ventricular extrasystoles requiring intervention or elevated troponin. Patients with associated myositis and whose only criterion for cardiac involvement was elevated troponin were not included in the group with cardiac involvement. Severe cardiac involvement was defined by the occurrence of hospitalization for cardiovascular reasons or by death of cardiovascular origin. Univariable and multivariable Cox proportional hazards models were used to determine variables associated with severe cardiac involvement occurrence. Survival analysis was performed using the Kaplan-Meier method with comparisons performed using the log rank test.

Results

Four hundred and fifty-nine patients with SSc were included and were followed for a median of 7.1 years [3.1; 13.3]. The median age of our population was 54 years old. There were 81% of women, 77% of patients had limited cutaneous SSc, 15% diffuse cutaneous SSc and 8% SSc sine scleroderma. Of the 459 patients, 105 (23%) had cardiac involvement and 56 (12%) severe cardiac involvement. The incidence of severe cardiac involvement was 2.42 per 100 patient years. Ninety-six hospitalizations were recorded, including 40 (42%) for acute heart failure, 19 (20%) for arrhythmia, 5 (5%) for acute pericarditis, 6 (6%) for acute myocarditis and 14 (15 %) for coronary artery disease (acute coronary syndrome, myocardial infarction or coronary revascularization). The independent factors associated with severe cardiac involvement in SSc were age over 54 years at SSc-diagnosis (OR = 3.21 95% CI [1.73; 5.95], p < 0.001), the presence of myositis (OR = 5.01 95% CI [1.89; 13.28], p = 0.001), pericardial involvement (OR = 3.79 95% CI [2.05; 7.03]; p < 0.001) or scleroderma renal crisis (OR = 4.72 95% CI [2.05; 10.92], p < 0.001). The survival rate of patients with severe cardiac involvement was 70% at 5 years and 53% at 10 years. Patients with severe cardiac involvement had a mortality risk three times greater than patients without severe cardiac involvement, HR = 3.1 (95% CI [1.7; 5.7], p<0.0001) (Figure 1). Pericardial involvement was an independent risk factor for mortality, HR = 2.0 (95% CI [1.02; 4.0], p=0.04).

Figure 1.

Survival of patients with severe cardiac involvement of systemic scleroderma. HR: Hazard ratio; 95% CI: 95% Confidence interval; Nb at risk: Number at risk

Conclusion

We need to focus our clinical attention on diagnosing and manage cardiac involvement in SSc, as severe cardiac involvement is not uncommon and is responsible for a poor prognosis.

Disclosure of Interests

None declared

Risk of Immune Thrombocytopenia After Influenza Vaccine

This cohort study uses data from the French National Health Database to examine the risk of immune thrombocytopenia after receiving influenza vaccine among patients who were 65 years or older.

Diagnostic Value of 18F-FDG PET/CT vs. Chest-Abdomen-Pelvis CT Scan in Management of Patients with Fever of Unknown Origin, Inflammation of Unknown Origin or Episodic Fever of Unknown Origin: A Comparative Multicentre Prospective Study

Fluorodesoxyglucose Positron Emission Tomography (PET/CT) has never been compared to Chest-Abdomen-Pelvis CT (CAPCT) in patients with a fever of unknown origin (FUO), inflammation of unknown origin (IUO) and episodic fever of unknown origin (EFUO) through a prospective and multicentre study. In this study, we investigated the diagnostic value of PET/CT compared to CAPCT in these patients. The trial was performed between 1 May 2008 through 28 February 2013 with 7 French University Hospital centres. Patients who fulfilled the FUO, IUO or EFUO criteria were included. Diagnostic orientation (DO), diagnostic contribution (DC) and time for diagnosis of both imaging resources were evaluated. One hundred and three patients were included with 35 FUO, 35 IUO and 33 EFUO patients. PET/CT showed both a higher DO (28.2% vs. 7.8%, p < 0.001) and DC (19.4% vs. 5.8%, p < 0.001) than CAPCT and reduced the time for diagnosis in patients (3.8 vs. 17.6 months, p = 0.02). Arthralgia (OR 4.90, p = 0.0012), DO of PET/CT (OR 4.09, p = 0.016), CRP > 30 mg/L (OR 3.70, p = 0.033), and chills (OR 3.06, p = 0.0248) were associated with the achievement of a diagnosis (Se: 89.1%, Sp: 56.8%). PET/CT both orients and contributes to diagnoses at a higher rate than CAPCT, especially in patients with FUO and IUO, and reduces the time for diagnosis.

Evaluation of lupus anticoagulant, damage, and remission as predictors of pregnancy complications in lupus women: the French GR2 study

OBJECTIVES

The specific roles of remission status, lupus low disease activity state (LLDAS), and damage accrual on the prognosis of pregnancies in women with systemic lupus erythematosus (SLE) are unknown. We analysed their impact on maternal flares and adverse pregnancy outcomes (APOs).

METHODS

We evaluated all women (≥18 years) with SLE enrolled in the prospective GR2 study with an ongoing singleton pregnancy at 12 weeks (one pregnancy/woman). Several sets of criteria were used to define remission, disease activity, and damage. APOs included: fetal/neonatal death, placental insufficiency with preterm delivery, and small-for-gestational-age birth weight. First trimester maternal and disease features were tested as predictors of maternal flares and APOs.

RESULTS

The study included 238 women (98.3% on hydroxychloroquine) with 230 live births. Thirty-five (14.7%) patients had at least one flare during the second/third trimester. At least one APO occurred in 34 (14.3%) women.Hypocomplementemia in the first trimester was the only factor associated with maternal flares later in pregnancy (p = 0.02), while several factors were associated with APOs. In the logistic regression models, damage by SLICC-Damage Index (OR 1.8, 95% CI: 1.1-2.9 for model 1 and OR 1.7, 95% CI: 1.1-2.8 for model 2) and lupus anticoagulant (LAC, OR 4.2, 95% CI: 1.8-9.7 for model 1; OR 3.7, 95% CI: 1.6-8.7 for model 2) were significantly associated with APOs.

CONCLUSION

LAC and damage at conception were predictors of APOs, and hypocomplementemia in the first trimester was associated with maternal flares later in pregnancy in a cohort of pregnant patients with well-controlled SLE.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, https://clinicaltrials.gov, NCT02450396.

Sine scleroderma, limited cutaneous, and diffused cutaneous systemic sclerosis survival and predictors of mortality

BACKGROUND

Systemic sclerosis (SSc) is associated with a variability of mortality rates in the literature.

OBJECTIVE

To determine the mortality and its predictors in a long-term follow-up of a bi-centric cohort of SSc patients.

METHODS

A retrospective observational study by systematically analyzing the medical records of patients diagnosed with SSc in Toulouse University Hospital and Ducuing Hospital. Standardized Mortality Ratio (SMR), mortality at 1, 3, 5, 10, and 15 years of disease and causes of death were described. Predictors of mortality using Cox regression were assessed.

RESULTS

Three hundred seventy-five patients were included: 63 with diffuse cutaneous SSc, 279 with limited cutaneous SSc, and 33 with sine scleroderma. The SMR ratio was 1.88 (95% CI 1.46-1.97). The overall survival rates were 97.6% at 1 year, 93.4% at 3 years, 87.1% at 5 years, 77.9% at 10 years, and 61.3% at 15 years. Sixty-nine deaths were recorded. 46.4% were SSc related deaths secondary to interstitial lung disease (ILD) (34.4%), pulmonary hypertension (31.2%), and digestive tract involvement (18.8%). 53.6% were non-related to SSc: cardiovascular disorders (37.8%) and various infections (35.1%) largely distanced those from cancer (13.5%). Four significant independent predictive factors were identified: carbon monoxide diffusing capacity (DLCO) < 70% (HR=3.01; p=0.0053), C-reactive protein (CRP) >5 mg/l (HR=2.13; p=0.0174), cardiac involvement (HR=2.86; p=0.0012), and the fact of being male (HR=3.25; p=0.0004).

CONCLUSION

Long-term data confirmed high mortality of SSc. Male sex, DLCO <70%, cardiac involvement, and CRP> 5mg/l were identified as independent predictors of mortality.

Presentation and Real-World Management of Giant Cell Arteritis (Artemis Study)

Background: Few studies of daily practice for patients with giant cell arteritis (GCA) are available. This French study aimed to describe the characteristics and management of GCA in a real-life setting.

Methods: Cross-sectional, non-interventional, multicenter study of patients ≥50 years old who consulted hospital-based specialists for GCA and were under treatment. Patient characteristics and journey, diagnostic methods and treatments were collected. Descriptive analyses were performed.

Results: In total, 306 patients (67% females, mean age 74 ± 8 years old) were recruited by 69 physicians (internists: 85%, rheumatologists: 15%); 13% of patients had newly diagnosed GCA (diagnosis-to-visit interval <6 weeks). Overall median disease duration was 13 months (interquartile range 5–26). Most patients were referred by general practitioners (56%), then ophthalmologists (10%) and neurologists (7%). Most common comorbidities were hypertension (46%), psychiatric disorders (10%), dyslipidemia (12%), diabetes (9%), and osteoporosis (6%). Initial GCA presentations included cranial symptoms (89%), constitutional symptoms (74%), polymyalgia rheumatica (48%), and/or other extra-cranial manifestations (35%). Overall, 85, 31, 26, and 30% of patients underwent temporal artery biopsy, high-resolution temporal artery Doppler ultrasonography, ¹⁸FDG-PET, and aortic angio-CT, respectively. All patients received glucocorticoids, which were ongoing for 89%; 29% also received adjunct medication(s) (methotrexate: 19%, tocilizumab: 15%). A total of 40% had relapse(s); the median time to the first relapse was 10 months. Also, 37% had comorbidity(ies) related to or aggravated by glucocorticoids therapy.

Conclusion: This large observational study provides insight into current medical practices for GCA. More than one third of patients had comorbidities related to glucocorticoid therapy for a median disease duration of 13 months. Methotrexate and tocilizumab were the most common adjunct medications.

USAID Associated with Myeloid Neoplasm and VEXAS Syndrome: Two Differential Diagnoses of Suspected Adult Onset Still's Disease in Elderly Patients

Background: Patients with solid cancers and hematopoietic malignancy can experience systemic symptoms compatible with adult-onset Still’s disease (AOSD). The newly described VEXAS, associated with somatic UBA1 mutations, exhibits an overlap of clinical and/or biological pictures with auto inflammatory signs and myelodysplastic syndrome (MDS). Objectives: To describe a cohort of patients with signs of undifferentiated systemic autoinflammatory disorder (USAID) concordant with AOSD and MDS/chronic myelomonocytic leukemia (CMML) and the prevalence of VEXAS proposed management and outcome. Methods: A French multicenter retrospective study from the MINHEMON study group also used for other published works with the support of multidisciplinary and complementary networks of physicians and a control group of 104 MDS/CMML. Results: Twenty-six patients were included with a median age at first signs of USAID of 70.5 years with male predominance (4:1). Five patients met the criteria for confirmed AOSD. The most frequent subtypes were MDS with a blast excess (31%) and MDS with multilineage dysplasia (18%). Seven patients presented with acute myeloid leukemia and twelve died during a median follow-up of 2.5 years. Six out of 18 tested patients displayed a somatic UBA1 mutation concordant with VEXAS, including one woman. High-dose corticosteroids led to a response in 13/16 cases and targeted biological therapy alone or in association in 10/12 patients (anakinra, tocilizumab, and infliximab). Azacytidine resulted in complete or partial response in systemic symptoms for 10/12 (83%) patients including 3 VEXAS. Conclusions: Systemic form of VEXAS syndrome can mimic AOSD. The suspicion of USAID or AOSD in older males with atypia should prompt an evaluation of underlying MDS and assessment of somatic UBA1 mutation.

Further characterization of clinical and laboratory features occurring in VEXAS syndrome in a large-scale analysis of multicenter case-series of 116 French patients

BACKGROUND

A new autoinflammatory syndrome related to somatic mutations of UBA1 was recently described and called VEXAS syndrome.

OBJECTIVE

To describe clinical characteristics, laboratory findings and outcomes of VEXAS syndrome.

DESIGN

Case-series.

SETTING

Patients referred to a French multicenter registry between November 2020 and May 2021.

PATIENTS

116 patients with VEXAS syndrome.

MEASUREMENTS

Frequency and median of parameters and vital status, from diagnosis to the end of the follow-up.

RESULTS

Main clinical features were skin lesions (83.5%), non-infectious fever (63.6%), weight loss (62%), lung involvement (49.6%), ocular symptoms (38.8%), relapsing chondritis (36.4%), venous thrombosis (34.7%), lymph nodes (33.9%), and arthralgia (27.3%). Hematological disease was present in 58 cases (50%), considered as myelodysplastic syndrome (MDS, n= 58) and monoclonal gammapathy of unknown significance (n=12).UBA1 mutations included p.M41T (44.8%), p.M41V (30.2%), p.M41L (18.1%), and splice mutations (6.9%). After a median follow-up of 3.0 years, 18 patients died (15.5%), from infectious origin (n=9) and MDS progression (n=3). Unsupervised analysis identified 3 clusters: cluster 1 (47%) with mild-to-moderate disease; cluster 2 (16%) with underlying MDS and higher mortality rates; cluster 3 (37%) with constitutional manifestations, higher C-reactive protein levels and less frequent chondritis. Five-year probability of survival was 84.2% in cluster 1, 50.5 % in cluster 2, and 89.6% in cluster 3. UBA1 p.Met41Leu mutation was associated with a better prognosis.

CONCLUSION

VEXAS syndrome displays a large spectrum of organ manifestations and shows different clinical and prognostic profiles. It also raises a potential impact of the identified UBA1 mutation.

Risk factors of hospitalisation for thrombosis in adults with primary immune thrombocytopenia, including disease-specific treatments: a French nationwide cohort study

We aimed to assess the risk factors of venous thrombosis (VT) and arterial thrombosis (AT) in adults with primary immune thrombocytopenia (ITP), particularly in relation to treatments. The population comprised all incident primary ITP adults in France between 2009 and 2017 (FAITH cohort; NCT03429660) built in the national health database. Outcomes were the first hospitalisation for VT and AT. Multivariable Cox regression models included baseline risk factors, time-varying exposure to ITP drugs, splenectomy and to cardiovascular drugs. The cohort included 10 039 patients. A higher risk of hospitalisation for VT was observed with older age, history of VT, history of cancer, splenectomy [hazard ratio (HR) 3·23, 95% confidence interval (CI) 2·26-4·61], exposure to corticosteroids (HR 3·55, 95% CI 2·74-4·58), thrombopoietin-receptor agonists (TPO-RAs; HR 2·28, 95% CI 1·59-3·26) and intravenous immunoglobulin (IVIg; HR 2·10, 95% CI 1·43-3·06). A higher risk of hospitalisation for AT was observed with older age, male sex, a history of cardiovascular disease, splenectomy (HR 1·50, 95% CI 1·12-2·03), exposure to IVIg (HR 1·85, 95% CI 1·36-2·52) and TPO-RAs (HR 1·64, 95% CI 1·26-2·13). Rituximab was not associated with an increased risk. These findings help to estimate the risk of thrombosis in adult patients with ITP and to select treatment.

Real-world Risk of Relapse of Giant Cell Arteritis Treated With Tocilizumab: A Retrospective Analysis of 43 Patients

OBJECTIVE

Tocilizumab (TCZ), an interleukin 6 (IL-6) receptor antagonist, is approved for giant cell arteritis (GCA) as a cortisone-sparing strategy and in refractory patients. This study assessed the real-world efficacy, safety, and long-term outcomes of patients with GCA treated with TCZ.

METHODS

We conducted a multicenter retrospective observational study at 3 French centers. All patients aged ≥ 50 years who met the American College of Rheumatology (ACR) criteria, and had received at least 1 dose of TCZ were included. Relapse was defined by therapeutic escalation, such as increased doses of corticosteroids (CS), resumption of CS after weaning, or introduction or intensification of adjuvant therapy.

RESULTS

Between 2013 and 2019, 43 patients were included. Patients were followed up for a median 511 days between GCA diagnosis and inclusion, with 34/43 (79%) patients experiencing relapses. At inclusion, median age was 77 years, and median dose of CS was 15 mg/day. After inclusion, the mean cumulative dose of CS was 2.1 g/year vs 9.4 g/year before inclusion (P < 2 × 10^-7), with 12/43 (28%) patients experiencing relapses on TCZ. Among 29 patients undergoing TCZ discontinuation, 18 (62%) experienced relapses. Factors associated with relapse after inclusion were introduction of TCZ > 6 months after diagnosis (P = 0.005), absence of ischemic signs at diagnosis (P = 0.006), relapse rate > 0.8/year (P = 0.03), and absence of CS tapering ≤ 5 mg/day (P = 0.03) before inclusion. Serious adverse events occurred in 18/43 patients (42%), including 4 deaths.

CONCLUSION

Our results confirm the effectiveness of TCZ for CS sparing, but after discontinuation of treatment, TCZ allows for a prolonged remission in < 50% of patients. Attention must be paid to the tolerance of this long-term treatment in this elderly, heavily treated refractory population.

Safety of Pyrazinamide for the Treatment of Tuberculosis in Older Patients Over 75 Years of Age: A Retrospective Monocentric Cohort Study

OBJECTIVES

Pyrazinamide (PZA) has a controversial safety profile in older patients. We aimed to assess the frequency and risk factors for adverse drug reactions (ADRs) in patients over 75 years of age treated for tuberculosis with or without PZA.

METHODS

We conducted a retrospective monocentric study including patients aged over 75 years treated for active tuberculosis between 2008 and 2018. The frequency, type, seriousness, and causality assessment of ADRs to anti-tuberculosis treatment were compared between patients receiving PZA or not. Risk factors for ADRs were investigated using univariable and multivariable analyses by logistic regression.

RESULTS

Among the 110 patients included, 54 (49.1%) received PZA (group 1) and 56 (50.9%) did not (group 2). ADRs to anti-tuberculosis drugs occurred in 31 patients (57.4%) in groups 1 and 15 (26.8%) in group 2 (p = 0.003). PZA-related ADRs occurred in 40.7% of exposed patients. Frequency of renal ADRs was higher in group 1 (9.3% vs 0%; p = 0.026). Rates of hepatic (18.5% vs 12.5%; p = 0.38), digestive (22.2% vs 8.9%; p = 0.054), and allergic (14.8% vs 5.4%; p = 0.12) ADRs were numerically higher in group 1 although the differences were not statistically significant. Serious ADRs occurred more frequently in group 1 (24.1% vs 8.9%; p = 0.03). The use of PZA was the only independent risk factor for ADRs to anti-tuberculosis drugs (odds ratio 3.75, 95% CI 1.5-9.6; p = 0.0056). No risk factors for PZA-related ADRs were identified.

CONCLUSION

In older French patients, the use of PZA was associated with more frequent ADRs to anti-tuberculosis drugs.

Hydroxychloroquine levels in patients with systemic lupus erythematosus: whole blood is preferable but serum levels also detect non-adherence

Background

Hydroxychloroquine (HCQ) levels can be measured in both serum and whole blood. No cut-off point for non-adherence has been established in serum nor have these methods ever been compared. The aims of this study were to compare these two approaches and determine if serum HCQ cut-off points can be established to identify non-adherent patients.

Methods

HCQ levels were measured in serum and whole blood from 573 patients with systemic lupus erythematosus (SLE). The risk factors for active SLE (SLEDAI score > 4) were identified by multiple logistic regression. Serum HCQ levels were measured in 68 additional patients known to be non-adherent, i.e. with whole-blood HCQ < 200 ng/mL.

Results

The mean (± SD) HCQ levels were 469 ± 223 ng/mL in serum and 916 ± 449 ng/mL in whole blood. The mean ratio of serum/whole-blood HCQ levels was 0.53 ± 0.15. In the multivariate analysis, low whole-blood HCQ levels (P = 0.023), but not serum HCQ levels, were independently associated with active SLE.

From the mean serum/whole-blood level ratio, a serum HCQ level of 106 ng/mL was extrapolated as the corresponding cut-off to identify non-adherent patients with a sensitivity of 0.87 (95% CI 0.76–0.94) and specificity of 0.89 (95% CI 0.72–0.98).

All serum HCQ levels of patients with whole-blood HCQ below the detectable level (< 20 ng/mL) were also undetectable (< 20 ng/mL).

Conclusions

These data suggest that whole blood is better than serum for assessing the pharmacokinetic/pharmacodynamic relation of HCQ. Our results support the use of serum HCQ levels to assess non-adherence when whole blood is unavailable.

Pulmonary mucormycosis following autologous hematopoietic stem cell transplantation for rapidly progressive diffuse cutaneous systemic sclerosis: A case report

RATIONALE

The use of autologous hematopoietic stem cell transplantation (AHSCT) for autoimmune diseases has become the first indication for transplant in nonmalignant disease. Mucormycosis is a rare invasive infection with increasing incidence in patients treated with AHSCT. We report the first case of pulmonary mucormycosis following AHSCT for systemic sclerosis (SSc).

PATIENT CONCERNS

A 24-year-old woman with rapidly progressive diffuse cutaneous SSc presented with an acute respiratory distress syndrome 6 days after AHSCT.

DIAGNOSES

The results of clinical and computed tomography scan were consistent with pulmonary mucormycosis and the diagnosis was confirmed by a positive Mucorales Polymerase Chain Reaction on a peripheral blood sample.

INTERVENTIONS AND OUTCOMES

Early antifungal therapy by intravenous amphotericin B provided rapid improvement within 4 days and sustained recovery after 2 years of follow-up.

LESSONS

With the progressively increasing use of AHSCT and other stem cell therapy for treatment of severe SSc and other autoimmune diseases, the potential onset of rare post-transplant fungal infections, such as mucormycosis, requires careful patient monitoring and better awareness of early initiation of adequate therapy.

SAT0339 NERVOUS SYSTEM INVOLVEMENT IN SYSTEMIC SCLEROSIS: A COHORT STUDY

Background:

Nervous system involvement is considered to be rare in systemic sclerosis (SSc). Its prevalence is highly variable in SSc cohort studies and its prognosis is not well established.

Objectives:

To determine the frequency, clinical characteristics, associations, and outcomes of different types of peripheral nervous system (PNS) and central nervous system (CNS) disease in a cohort of systemic sclerosis patients.

Methods:

We have carried out a retrospective observational study by systematically analyzing the medical records of patients diagnosed with SSc in Toulouse University Hospital and Ducuing Hospital, south west France. We included patients who met the following inclusion criteria: being over 18 years of age on diagnosis, meeting the ACR /EULAR 2013 classification criteria, being diagnosed after 01/01/1966 and before 31/12/2018, at least 12 months of follow-up. Patients were followed until 31/12/2019. Nervous system involvement associated with SSc was included when there was involvement on or after diagnosis and after exclusion of all other causes. Only symptomatic clinical involvement was included. Ischemic or hemorrhagic strokes were excluded. We calculated the incidence of CNS and/or PNS disease during the follow-up period per 1,000 person-years. Kaplan-Meier curves were plotted to determine the cumulative incidence of nervous system disease. We evaluated associated factors of CNS and/or PNS disease using multivariable Cox regression.

Results:

Of 447 SSc patients, 79.8% were female, 68 (15%) were diffuse cutaneous SSc, 342 (77%) were limited cutaneous SSc and 37 (8%) were sine scleroderma SSc. The mean ± SD age at diagnosis was 52.9 ± 14.3 years.

During the study period, 82 (18%) patients experienced a PNS disease, 29 (6%) a CNS disease. The incidence was 28 per 1,000 patient-years of any nervous system disease, with 22 per 1,000 patient-years and 6 per 1,000 patient-years of PNS disease and CNS disease, respectively. The most frequent were carpal tunnel syndrome (63%) and polyneuropathies (12%) for PNS disease, and headache (45%) and seizures (10%) for CNS disease.

Three significant independent associated factors with PNS disease occurrence were identified using multivariable Cox regression: BMI>23.1kg/m2(HR = 1.06 [1.01-1.12]), joint involvement (HR = 2.7 [1.3-5.5]), and an alteration in the left ventricular ejection fraction (HR = 3.8 [1.4-10.3]).

Four significant independent associated factors with CNS disease occurrence were identified: age > 54 years (HR = 2.5 [1.1-6.0]), positive anti-PmScl testing (HR = 6.4 [1.5-28.2]), Caucasian origin (HR = 0.2 [0.1-0.5]) and hemoglobin < 12g/dl (HR = 0.2 [0.04-0.8]).

Nervous system disease occurrence did not appear to have a negative impact on the survival of SSc patients (log-rank p=0.56).

Conclusion:

This study shows that specific nervous system disease in SSc is not uncommon and does not appear to increase mortality, but it could have an impact on functional prognosis and needs to be monitored.

Disclosure of Interest:

None declared

AB1095 DIAGNOSTIC PERFORMANCE OF THE AORTIC WALL THICKENING DETERMINED BY ROUTINE CT-SCAN FOR THE DIAGNOSIS OF AORTITIS OVER 50 YEARS OF AGE

Background:

Making the diagnosis of aortitis may be challenging in the “real life”.18F-FDG PET/CT (PET) has emerged has the gold standard to diagnose aortitis but it is expensive and not always quickly available. Injected CT-scan (CT) can also be used to diagnose aortitis, which is suspected when there is an extended circumferential, non-atherosclerotic increase of the aortic wall thickness (AWT). However, data are lacking on the diagnostic performances of AWT to diagnose aortitis.

Objectives:

To describe the diagnostic performance of AWT measured by CT to diagnose aortitis in patients over 50 years of age.

Methods:

We performed a monocentric retrospective study between 2013 and 2018 including 1) all patients over 50 years of age who had performed a PET for inflammation or fever of unknown origin or for suspicion of classical giant cell arteritis (GCA), aortitis or large vessel vasculitis (LVV); 2) with an injected CT-scan performed in the 30 days before or after PET; 3) not diagnosed to have cancer or infection 4) exposed to corticosteroids for less than 3 days at the time of CT and PET. The gold standard for aortitis was PET positivity according to the 2018 European consensus grading criteria (1). AWT was measured at different aortic segments (ascending aorta, descending thoracic aorta and suprarenal abdominal aorta) by a single radiologist unaware of the result of PET and of the previous interpretation of CT-scan.

Results:

Eighty-nine patients were included (female: 47%; mean age 68.8 (50-93) years; GCA: n=28). Twenty patients had aortitis according to the PET result (GCA: n=16).

Mean maximal aortic wall thickening was: 3.25 mm (median: 3.3; range: 2-4.6) in the aortitis group and 2.2 mm (median: 2.1; range 1-3.8) in the negative PET group (p < 0.001).

The best ROC curve AUC (85%) was obtained considering the maximal AWT on the thoracic and suprarenal abdominal aorta only. The AUC of the ROC curve at the ascendant thoracic aorta was poor (75%) (Figure).

The Youden’s index of the ROC curve was 2.6 mm with a sensitivity of 85 % and specificity of 71 % (Table) for aortitis diagnosis. An AWT ≤ 2.0 mm exclude the diagnosis of aortitis. The 3 mm threshold had a PPV of only 52% and an AWT ≥ 4 mm was fully specific.

Conclusion:

Aortitis diagnosis using a routine injected CT-scan interpreted by a single radiologist may be certain when showing an AWT ≥ 4 and excluded for an AWT≤ 2.0. The threshold of 3 mm seems not sufficiently specific to diagnose aortitis without a confirmatory PET.

References:

[1]Riemer H.J.A. Slart et al. FDG-PET/CT(A) imaging in large vessel vasculitis and polymyalgia rheumatica: joint procedural recommendation of the EANM, SNMMI, and the PET Interest Group (PIG), and endorsed by the ASNC. Eur J Nucl Med Mol Imaging. 2018 Jul;45(7):1250–69.

Table.

Performance of different threshold for maximal thickness of the aortic wall for diagnosis of aortitis using PET positivity as the gold standard*.

Thickness (mm)SensitivitySpecificityNPVPPVaccuracy≥ 1.9100 %30.4%100 %29.41 %46 %≥ 2.0100 %31.88 %100 %29.85 %47 %≥ 2.295 %53.62 %97.36 %37.25 %63 %≥ 2.685 %71.01 %94.23 %45.94 %74 %≥ 3.060 %84.05 %87.88 %52.17 %78 %≥ 3.360 %92.75 %88.89 %70.59 %85 %≥ 3.535 %95.65 %83.54 %70 %82 %≥ 3.825 %98.55 %81.92 %83.33 %82 %≥ 4.020 %100 %81.17 %100 %82 %

*Made with ROC curve in descendant thoracic and suprarenal segment of the aorta; PET:18F-FDG PET/CT; NPV: negative predictive value; PPV: positive predictive value.

Figure.

ROC curve of aortic wall thickness, in descendant thoracic and suprarenal abdominal segments for the diagnosis of aortitis.

Disclosure of Interests:

None declared

High rate of indeterminate results of the QuantiFERON-TB Gold in-tube test, third generation, in patients with systemic vasculitis

OBJECTIVES

To describe the frequency of QuantiFERON-TB Gold in-tube test® (QFT-GIT) indeterminate results due to no response to phytohaemagglutinin A stimulation in the control tube in vasculitis patients prior to immunosuppressant therapy; and to compare it with other groups of patients.

METHODS

This was a single-centre, retrospective study. Patients and controls were included between 1 January 2008 and 31 December 2015. We assessed the rate of indeterminate results of the QFT-GIT in 38 patients with systemic vasculitis prior to any corticosteroid or immunosuppressant therapy, compared with 40 non-vasculitis patients with biological inflammatory syndrome, and 310 non-immunosuppressed patients matched for gender and age.

RESULTS

Indeterminate results due to no response to phytohaemagglutinin A were more frequent in vasculitis patients (21.1%) compared with non-vasculitis patients with biological inflammatory syndrome (7.5%) (Fisher's exact test: P = 0.11) and to anonymized controls (7%) (P = 0.009). Responses to phytohaemagglutinin A were significantly lower in vasculitis patients compared with other groups (Kruskal-Wallis test: P < 0.0001) and compared with non-vasculitis patients with biological inflammatory syndrome (P = 0.0015). The multivariable analysis identified as independent predictors of an indeterminate result of the QFT-GIT: the presence of systemic vasculitis (odds ratio 9.64 [1.14-81.3], P = 0.037) and a high neutrophil-to-lymphocyte ratio (odds ratio 1.70 [1.21-2.37], P = 0.002). One patient with an indeterminate result of QFT-GIT developed active tuberculosis after one year of corticosteroid therapy for giant cell arteritis.

CONCLUSION

Our results question the reliability of QFT-GIT to rule out latent tuberculosis in vasculitis patients at diagnosis, prior to immunosuppressant therapy.