AB0359 TOCILIZUMAB IN AFRO-CARIBBEAN RHEUMATOID ARTHRITIS: THE MARTINICAN EXPERIENCE

Background

Mortality and morbidity related to rheumatoid arthritis (RA) has remarkably improved over the last twenty years since using biologics DMARDs1. However, their effectiveness remains questionable in Afro-descendants (AD) due to their large under-representation in RA clinical trials2,3. Martinique is a French Caribbean region with a majority of AD population4, with free access to healthcare, including biotherapies, and a unique university hospital and rheumatology unit.

Objectives

To evaluate effectiveness of Tocilizumab (TCZ), an interleukin-6 inhibitor, in an afro descendant RA population.

Methods

Retrospective cohort of 171 patients who received at least 1 infusion of Tocilizumab (IV TCZ) at Martinique University Hospital Center between 2008 and 2019. Inclusion Criteria: Patients over 18 y/o meeting RA 2010 ACR/EULAR criteria, having received at least 4 courses of IV TCZ starting at 8mg/kg every 4 weeks, with available baseline clinical/biological data. Exclusion criteria: Patients having received subcutaneous TCZ (SC TCZ) prior to IV TCZ, not living in Martinique. Primary endpoint was proportion of patients in remission (R) and low disease activity (LDA) according to DAS28 CRP at 12, 24, 36 weeks. Secondary endpoint was proportion of patients achieving good (GR) and moderate (MR) EULAR response criteria 5 at 12, 24 and 36 weeks, and TCZ retention at 1 year defined as the proportion of patient receiving TCZ at 1 year follow up.

Results

Out of 171 patients receiving IV TCZ, we identified 138 RA and 80 patients met inclusion criteria: 90% were women, mean age was 56.8 (± 11.8) y/o, mean duration of RA was 11.6 (± 8.9) years, ACPA and Rheumatoid Factor were positive in 72.1% and 73% of cases, 69.6% of patients had erosions and 77.8% had received at least 1 biologic prior to IV TCZ. At baseline, 8 patients were in R, 8 had LDA but presented steroid dependency over 10 mg per day of prednisone and mean dose of prednisone was 6.9 (+/- 6.7) mg per day.

At 12, 24, 36 weeks, R was achieved in 44.8%, 55.2% and 51.2% of patients and LDA in 37.3%, 17.2% and 20.9%, respectively (Figure 1). At 12, 24, 36 weeks, GR was achieved in 44.8 %, 60.3% and 48.8% of patients respectively, MR was achieved in 20.9%, 20.7% and 27.9% of patients respectively (Figure 1) and mean dose of prednisone per day was 5.1 (± 4.9) mg, 4.9 (± 5.6) mg and 3.3 (± 5.1) mg respectively. At 1 year, 78.8% of patients were still on TCZ. During follow up: 15 patients experienced 19 infectious events; 6 patients liver cytolysis; 12 patients neutropenia. No patient died.

Conclusion

This is the first study evaluating efficacy and safety of TCZ in an AD RA cohort. TCZ is safe and effective in our AD population with comparable data observed in other ethnicities6,7.

References

[1]Lacaille, D., Avina-Zubieta, J. A., Sayre, E. C. & Abrahamowicz, M. Improvement in 5-year mortality in incident rheumatoid arthritis compared with the general population—closing the mortality gap. Ann. Rheum. Dis.76, 1057–1063 (2017).

[2]Strait, A. et al. Demographic Characteristics of Participants in Rheumatoid Arthritis Randomized Clinical Trials: A Systematic Review. JAMA Netw. Open2, e1914745 (2019).

[3]Dunbar-Jacob, J. et al. Factors associated with attrition of African Americans during the recruitment phase of a clinical trial examining adherence among individuals with rheumatoid arthritis: Attrition of African Americans. Arthritis Care Res.51, 422–428 (2004).

[4]Levinson, D. Ethnic Groups Worldwide : a ready handbook. (1998).

[5]Fransen, J. & van Riel, P. L. C. M. The Disease Activity Score and the EULAR Response Criteria. Rheum. Dis. Clin. N. Am.35, 745–757 (2009).

[6]Gottenberg, J.-E. et al. Comparative effectiveness of rituximab, abatacept, and tocilizumab in adults with rheumatoid arthritis and inadequate response to TNF inhibitors: prospective cohort study. BMJ l67 (2019) doi:10.1136/bmj.l67.

[7]Mori, S. et al. Retention of tocilizumab with and without methotrexate during maintenance therapy for rheumatoid arthritis: the ACTRA-RI cohort study. Rheumatology58, 1274–1284 (2019).

Disclosure of Interests

None declared

POS0945 NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN THE AFRO-CARIBBEAN POPULATION, CLINICAL ASPECTS AND PARTICULARITIES

Background:

Spondyloarthritis is a polymorphic disease and the absence of diagnostic marker has led to propose diagnostic criteria for recognition. All the criteria, established in Caucasian populations, place at the center of the approach sacroiliac imaging and genetic terrain (HLA B27). For this reason, these criteria are not appropriate in populations lacking HLA B27. SPA is known to be rare in African populations and this rarity correlates with that of HLA B27.Prevalence of B27 in French West Indies is 2% (identical to the African populations).

Objectives:

We report clinical manifestations of SpA seen at the Fort de France University Hospital, with an emphasis on the so-called “non-radiographic SpA” (NRSPA).

Methods:

Adult patients with spondyloarthritis seen over a period of three consecutive months, were invited to participate in a survey and filled-in a self-administered questionnaire. The consulting rheumatologist specified the rheumatologic and extra-articular involvement, BASDAI score, HLAB27 data, markers of inflammation and imaging.

Results:

There were 93 patients, 47 with radiographic sacroilitis (RSPA) and 46 patients without but all - these 46 - had magnetic sacroilitis. This population is Afro-Caribbean for 98%. Mean age at onset of clinical signs is 38.5 ± 15.0 years and median age is 37.0 (13-77). An evocative family history is noted in 37%. All these 93 patients suffer from rachialgia.

But the axial complaint is often secondary to the peripheral involvement. 3 patients have a mechanical spinal complaint. All the others have intermittent inflammatory complaint evolving by flares affecting all the spinal stages. 15/93 patients have isolated axial complain without peripheral disease. Enthesopathies are seen in 70%.

Peripheral inflammatory joint complain is observed in 78 patients (84%), it is a bilateral and symmetrical chronic polyarticular pattern affecting (70/78) the small joints of the hands, forefeet and wrists. Ankle bi-arthritis is almost systematic and is observed in 71/78 patients; 8 patients with RSPA had no polyarthritis but oligo (6) or monoarthritis (2). Peripheral inflammatory joint is more frequent in NRSPA than in RSPA (98% vs 70%). Ultrasound individualises grade II synovitis (78/78), rarely with a Doppler effect (5/78). On average, more painful and swollen joints are observed in NRSPA than in RSPA. Extra articular and immunological aspects and activity scores are in table 1.

Good sensitivity of peripheral arthritis to NSAIDs and MTX is noted in 94 and 91%.

Conclusion:

NRSpA are not uncommon in the Afro-Caribbean population, but are distinct from Caucasian SpA by several points: female predominance, rarity of B27 and syndesmophytes, frequency of polyalgic pattern, frequency of peripheral arthritis, rarity of extra-articular manifestations, more frequent but less marked inflammation, good response of arthritis to NSAIDs and MTX. Appropriate classification criteria for Afro-descendant populations is an urgent unmet need.

References:

[1](López-Medina C, et al. RMD Open 2019;5:e001108).

Table 1.

Extra articular manifestations, activity scores and immunological aspects of the patients.

ItemResults (%)NRSPA n=46Results (%)RSPA n=47Dactylitis11 (23 %)13 (27 %)Uvéïtis5 (11 %) (p 0.02)15 (32%)Psoriasis1 (2 %)1 (2 %)IBD4 (9 %) (p 0.02)10 (21 %)Balanitis00Non gonococcal urethritis00Non gonococcal cervicitis00High CRP (at least 2 measure)21 (45%) (p 0.03)30 (63%)Mean CRP mg/l6 ± 4 17 ± 7BASDAI4.1 ± 0.24 ± 0.2EVA pain4.5 ± 0.44,5 ± 0.2HAQ0.6 ± 0.30,5 ± 0.2EVA Global4.9 ± 0.84,8 + 0.8EVA Spine5 ± 0.54,1 + 0.9FIRST score >55 /46 patients (10.9%)6 / 47 patients (12.5%)HLA B27 presence4/46 (8.7%) (p 0.01)14/47 (29.8%)Sexemale 10 (21.3%) (p 0.001)male 19 (51.3%)ACPA00Latex Waaler-Rose1 (low titer, > 65 years)1 (low titer, > 65 years)ANA2 (low titer, < 1/320°)3 (low titer, < 1/320°)

Disclosure of Interests:

None declared

Lessons for lupus from tumour necrosis factor blockade

Systemic lupus erythematosus (SLE) is a systemic non-organ specific autoimmune disease associated with multiple autoantibodies targeting autoantigens from the nucleus. Given the complex pathophysiology of SLE and the role of TNF alpha in that disease, modulation of TNF alpha (in SLE or non-SLE patients) using TNF blockers could either be detrimental or beneficial in some patients. In this review we will focus on lupus autoantibodies and clinical manifestations after TNF blockade in SLE patients and conversely on drug-induced-SLE in non-SLE patients. Some hypotheses regarding the mechanism of induction of autoantibodies in RA patients treated with TNF blockers are proposed.

Incidence and characteristics of proximal femoral fractures in an Afro-Caribbean population

BACKGROUND

Although fractures of the proximal femur (FPF) are supposedly less frequent in Black populations (studies of incidence are rare) the life expectancy in Africa is low, which could partially explain this notion. There is only one retrospective study on the incidence of FPF in the islands of the Caribbean, thus we performed an incidence study in the insular, circumscribed, 90% Afro-Caribbean population of Martinique. The goals of this study were: (1) to estimate the incidence of FPF; (2) and to prospectively describe the main characteristics.

HYPOTHESIS

The incidence of fractures of the proximal femur in Martinique is lower than in Western countries.

PATIENTS AND METHODS

The raw and standardized incidence ratio of FPF in relation to the world population was estimated based on data from the Medical Information System Program (Programme de médicalisation des systèmes d'information [PMSI]) for all of Martinique for a period of 4 years (January 1, 2010 to December 31, 2013). Characteristics were based on all patients over the age of 60 who presented to the Fort-de-France University Hospital (CHU) for a FPF between December 1, 2011 and April 31, 2012. Patients with light-skin phenotype, high-energy fractures and secondary fractures were excluded from the study.

RESULTS

The standardized incidence ratio in relation to the world population was estimated (n=794) as 22.5/100,000 patient-years [20.6-24.4]: 22.6 and 22.4/100,000 in men and women respectively. The characteristics of eighty-seven patients (including 56 women), mean age 85.3 (±7.2) (62-100) years old were evaluated: 52 femoral neck fractures (60%) and 33 fractures of the greater trochanter (38%). The 2-month mortality rate was 21%, and 1/3 of the surviving patients could function independently. The risk of death increased in relation to the initial risk of moderate to severe dementia.

DISCUSSION

The incidence of FPF in Martinique is lower than in Western countries and includes, as expected, an elderly, female population. Unlike a previous study performed in Guadeloupe, there was a majority of femoral neck fractures. A Caribbean multi-insular study is needed to confirm these results and to obtain precise data on bone density.

LEVEL OF EVIDENCE

IV; descriptive prospective epidemiological study.

Validity of the polymyalgia rheumatica activity score in primary care practice

OBJECTIVE

To evaluate the validity and reliability of the polymyalgia rheumatica (PMR) activity score (PMR-AS) for relapse diagnosis by general practitioners (GPs) who manage a large proportion of patients with PMR.

METHODS

Seven clinical vignettes of PMR were used, for which 35 rheumatologists previously made a diagnosis of relapse or no relapse with greater than 80% agreement. These vignettes were submitted to 163 GPs, who were asked to assess disease activity using a visual analogue scale (VASph), this being the only physician-dependent component of the PMR-AS. The 1116 available vignette-GP combinations were used to assess differences in VASph assessed by GPs versus rheumatologists. Statistical associations linking a relapse diagnosis by the rheumatologists (the reference standard) to the value of the GP-assessed PMR-AS or its components (GP-assessed VASph, visual analogue scale pain score, C-reactive protein, morning stiffness and elevation of upper limbs) were evaluated.

RESULTS

No significant differences were found between VASph scores by GPs versus rheumatologists for any of the vignettes. A relapse diagnosis was strongly associated with PMR-AS values of 7 or more (sensitivity 99.4%; specificity 93.3%; agreement 95.9% (95% CI 94.5% to 97.0%) with kappa = 0.92). Of the 590 GP-vignette combinations with PMR-AS values lower than 7, all but three (0.5%) had no relapse diagnosis. Of 510 combinations with PMR-AS values of 7 or more, only 42 (8%) had no flare diagnosis.

CONCLUSIONS

This study supports the validity of the PMR-AS in primary care practice and provides evidence that a good scoring system can be useful to guide clinical and therapeutic decisions.

Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology

OBJECTIVE

To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months' duration.

METHODS

Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): < or =3.2; >3.2 and < or =5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)-that is, 3 x 2 x 2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method.

RESULTS

Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity.

CONCLUSIONS

Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.

Crowned dens syndrome misdiagnosed as polymyalgia rheumatica, giant cell arteritis, meningitis or spondylitis: an analysis of eight cases

BACKGROUND

The crowned dens syndrome, related to microcrystalline deposition in the peri-odontoid articular and abarticular structures, is mainly responsible for acute or chronic cervical pain.

PATIENTS

We report eight cases of crowned dens syndrome with atypical presentations mimicking giant cell arteritis, polymyalgia rheumatica, meningitis or discitis. The clinical and radiological aspects of these cases are presented and discussed.

RESULTS

For all patients, fever, cervical stiffness, headaches and biological inflammatory syndrome were reported. For three patients, impairment of general condition, occipito-temporal or mandible pain and weakness with inflammatory pain of the shoulder girdle was suggestive of giant cell arteritis and/or polymyalgia rheumatica, leading to temporal artery biopsy and/or long-term steroid treatment. Recurrence of clinical symptoms when tapering steroids was noted. In two cases, previous breast carcinoma led to the initial diagnosis of metastatic spondylitis. For three patients with vomiting, nausea and Kernig's and/or Brudzinski's sign, the first diagnosis was meningitis, leading to unhelpful lumbar puncture. In all cases, diagnosis of crowned dens syndrome once evoked, was confirmed by cervical CT scanning and dramatic improvement with non-steroidal anti-inflammatory drugs or colchicine.

CONCLUSION

This under-recognized entity must be considered as a differential diagnosis of meningitis and discitis, but also of giant cell arteritis and polymyalgia rheumatica, as well as a possible aetiology for fevers of unknown origin. CT scanning is necessary for diagnosis. Clinicians should be aware of such misleading clinical presentations.

Rheumatoid arthritis and schizophrenia: a negative association at a dimensional level

There is wide evidence for a decreased risk of rheumatoid arthritis in patients with schizophrenia. Nevertheless, very few studies have looked at the risk of schizophrenia in a group of patients with rheumatoid arthritis. We prospectively investigated, with the SCL-90R, 220 consecutive outpatients with rheumatoid arthritis and 196 consecutive outpatients with various medical conditions, half of them suffering from psoriatic arthritis (a medical condition close to rheumatoid arthritis). The SCL-90R appears to be a valuable tool to distinguish patients with schizophrenia from the outpatients of our sample, the former having more "paranoid ideation" (p = 0.004) and more "psychoticism" (p < 0.001) than the latter. The "paranoid ideation" dimension was significantly lower (25% decrease) in the sample of patients with rheumatoid arthritis compared to the combined control group (p = 0.005), ratings under the median value being more frequent in the former group (p = 0.025). Confounding factors might not explain this difference according to the regression logistic analysis performed. As patients with rheumatoid arthritis have a lower score of paranoid ideation than controls in our sample, even after controlling for age, gender and severity of the disease, these data represent further evidence for a decreased risk of schizophrenia in individuals with rheumatoid arthritis.

[Crowned dens syndrome: three new cases]

INTRODUCTION

Crowned dens syndrome is due to a microcrystalline infringement (hydroxyapatite or calcium pyrophosphate) of the retro-odontoidal ligament of atlas, often leading to the erroneous diagnosis of meningitis or spondylitis. We report on three new cases diagnosed from 1996 to 1999.

EXEGESIS

The patients complained of cervicalgies, headaches or fever. The initially evoked diagnoses were meningitis, spondylodiscitis or endocarditis. Clinical exam found meningism and an inflammatory syndrome in all patients. Analysis of the cerebro-spinal fluid realised in two cases was normal. The diagnosis of crowned dens syndrome was assessed in two cases by cervical CT scan of C1/C2. In the third case, chondrocalcinosis of a wrist allowed this diagnosis. We report a probably non fortuitous case of crowned dens syndrome associated with genetic hemochromatosis. A non steroidal anti-inflammatory treatment allowed a dramatic regression of clinical symptoms.

CONCLUSION

This entity should be better known; it can mimick numerous diagnosis and be responsible for fever in the long course.

Differences in understanding and application of 1987 ACR criteria for rheumatoid arthritis and 1991 ESSG criteria for spondylarthropathy. A pilot survey

OBJECTIVES

To determine areas of agreement and disagreement among experts in the interpretation of the published criteria for RA (ACR) and spondylarthropathies ( ESSG).

METHODS

Thirty-two experts (16 from France and 16 from 10 other countries) replied anonymously to a mailed questionnaire.

RESULTS

Tenosynovitis and 'sausage-like' painless swelling of the toes were considered as criteria for RA by 18 and 14 experts, respectively. The definition of symmetry differed widely among experts (symmetry of only one group of joints was sufficient for 13). Twenty-five experts considered erosions of other joints than the wrists and fingers as a criterion for RA, 17 thought that fulfilment of criteria could be achieved cumulatively, and 19 would appreciate clarifications of the current criteria. Among possible clarifications for RA, it was frequently recommended that morning stiffness and nodules be eliminated and that new marker antibodies, X-rays of the feet, and exclusion criteria be added. Twenty-three of the 29 experts who gave an opinion (79%) agreed with the notion of SP in the absence of axial signs and sacroiliitis, 26/31 (84%) indicated that a patient can have both RA and SP, and 19/30 (63%) thought that RA and SP could be regarded as syndromes more than diseases. Only 5/32 experts relied more on the criteria than on their clinical judgement in diagnosing RA.

CONCLUSIONS

There would seem to be a needfor the optimisation of RA and ESSG criteria, particularly within the context of early arthritis.

Angiogenesis: general mechanisms and implications for rheumatoid arthritis

In rheumatoid arthritis, the vascular endothelium is among the key targets for circulating mediators of inflammation and controls the trafficking of cells and molecules from the bloodstream toward the synovial tissue. Local blood vessel proliferation allows the pannus to develop and grow, thereby promoting cartilage and bone destruction and joint remodeling. Angiogenesis, the production of new capillaries from preexisting blood vessels, is a key process in rheumatoid arthritis that involves multiple substances such as cytokines, chemokines, growth factors, cell adhesion molecules, proteinases, proteinase inhibitors, and matrix proteins. In animal models of arthritis, angiogenesis inhibitors have been found to improve clinical and radiological outcomes, opening up the possibility of therapeutic applications in humans. Before this possibility is realized, the steady accumulation of data on the mechanisms that regulate angiogenesis will have to continue until a clear picture of angiogenesis is formed.

[Outcome of pregnancies in lupus: experience at one center]

We determined the outcome of all pregnancies in SLE patients in our lupus cohort between 1991 and 1997. The women were advised that pregnancy was acceptable if the disease had been inactive for 6 months (SLEDAI < or = (4 at 2 serial examinations) and daily prednisone dose was below 10 mg. Patients were advised against pregnancy in case of active nephritis or neurolupus. In case of antiphospholipid antibodies, patients were treated with aspirin or heparin if previous fetal losses were documented. In case of anti-SSA ab, patients were monitored with ultrasound and given dexamethasone in case of atrioventricular block. Fifty-nine pregnancies were registered among 31 women: mean age at diagnosis of SLE was 25.3 +/- 3.7 years (range: 17-31); mean disease duration before pregnancy 4.4 +/- 3 years (0-14); mean ACR score 5.4 +/- 1.5 (4-9). Seven patients had ACL ab, 8 had anti-SSA ab. Pregnancies ended in: 13 early spontaneous abortions (9 not related to disease flare up, 4 related to SAPL); 7 elective abortions (patient decision in 5 cases, severe lupus flare up in 2); one in utero death; 19 full term births (> 38 weeks); and 19 preterm births. Cesarean section was performed in 11 cases (6 for fetal distress, dystocia and previous ceasarian; 5 for active lupus). Severe sepsis occurred in one premature infant who died at the age of 1 week. Intrauterine growth retardation was observed in 11 cases, mean APGAR score was 8.9 +/- 1.43. Child development was normal in all cases except one child with mild mental retardation. Severe lupus flare ups occurred in 6 cases, of which 4 were pregnancies in unadvised situations. Six mild flare ups were documented in the post partum. One fatal case of neonatal lupus with AVB was observed. In conclusion, in our experience, the live birth rate is similar to the general population and the risk of lupus flare up is low when the above mentioned criteria are applied. Systematic increase of steroid dose at pregnancy onset does not seem to be necessary. The high rate of prematurity remains a problem to be solved.

Classification of an intermediate group of patients with antiphospholipid syndrome and lupus-like disease: primary or secondary antiphospholipid syndrome?

OBJECTIVE

(1) To classify an intermediate group of patients (IntAPS) with antiphospholipid syndrome (APS) and lupus-like disease either as primary (PAPS) or secondary APS (SAPS) and to discuss 2 different classifications. (2) To compare patients of a division of rheumatology with either PAPS or SAPS.

METHODS

Patients with APS and patients with systemic lupus erythematosus (SLE) followed at the Department of Rheumatology, University Hospital Bichat, Paris, from 1987 to 1996 were analyzed. A chart review and a standardized telephone interview in 1997 completed the data of this study.

RESULTS

(1) We found a total of 108 patients with APS: 22 with PAPS, 69 with SAPS, and 17 with IntAPS. The group of IntAPS did not differ from PAPS in any clinical or laboratory signs with the exception of antibodies to dsDNA and to extractable nuclear antigen (ENA). Between IntAPS and SAPS, there were several significant differences in clinical signs of SLE (malar rash, discoid rash, arthralgia) and in laboratory values (leukocytopenia). (2) Comparison of PAPS and SAPS showed statistically significant differences for positive Coombs' test, leukocytopenia, lymphocytopenia, antinuclear antibodies, antibodies to dsDNA and to ENA, and hypocomplementemia.

CONCLUSION

The mainstay of the diagnosis of APS is the clinical event of thrombosis or miscarriage in the presence of antiphospholipid antibodies. Less important are laboratory values, which may help to differentiate PAPS from SAPS in order to initiate adequate therapy (e.g., anticoagulation in the first and additional corticosteroids in the second). Patients with IntAPS are more likely to be integrated into the group of PAPS than in the group of SAPS; therefore, special exclusion criteria for PAPS are not appropriate.

Anti-heat shock protein 70 kDa and 90 kDa antibodies in serum of patients with rheumatoid arthritis

OBJECTIVES

Stress proteins (HSPs) are highly conserved immunodominant antigens found in various species. The purpose of this study was to assess the prevalence and prognostic significance of antibodies to HSC 70 kDa and HSP 90 kDa in three groups of patients with longstanding rheumatoid arthritis (RA) defined based on the severity of articular erosions.

METHODS

73 patients with longstanding (> 6 years) RA whose HLA-DR genotype was known were divided in three groups according to Larsen's score and compared with 47 recent onset (<1 year) RA patients and with control groups composed of patients with other inflammatory diseases (n=137) or of normal controls (n=48). IgGs and IgMs to HSC 70 kDa and HSP 90 kDa were determined using an ELISA with purified bovine HSC 70kDa or HSP 90 kDa.

RESULTS

Concentrations of IgGs and IgMs to HSC 70 were significantly increased in 41.1% and 42.5% of longstanding RA patients, respectively. Corresponding figures for IgGs and IgMs to HSP 90 were 39.7% and 56%. IgMs to HSC 70 and HSP 90 were less frequent in recent onset RA (19% and 13% respectively). Among the groups with other inflammatory diseases, only the MCTD group exhibited high frequencies of IgGs to HSC 70 (80%) and HSP 90 (85%). DRB1*0401 positive RA patients (n=23) were not more likely to have increased concentrations of antibodies to HSC 70 kDa or HSP 90 kDa than other RA patients (DR4 positive but DRB1*0401 negative, or DR1 positive, n=31; or negative for both DR4 and DR1, n=14). IgGs to HSP 90 kDa were significantly more frequent (p<0.05) in longstanding RA patients whose Larsen's score was 4 or more (57%) than in those whose Larsen's score was 2 or 3 (39.4%) or less than 2 (16%). No associations were found between Larsen's score and IgGs or IgMs to HSC 70 kDa or IgMs to HSP 90 kDa. A significant correlation was demonstrated between IgGs to HSP 90 kDa and two other serological markers for RA, rheumatoid factor, and anti-Sa antibody; there were no correlations with antikeratin antibody, antiperinuclear factor, or anti-RA 33.

CONCLUSION

IgGs to HSP 90 kDa are most common in longstanding RA patients with articular erosions, suggesting that they may be related to the articular prognosis in RA

Anti-proteinase-3 (PR3) antibodies (C-ANCA) recognize various targets on the human umbilical vein endothelial cell (HUVEC) membrane

Numerous studies suggest that C-ANCA are directly pathogenic in vasculitis by activating leucocytes (oxidative burst, enzyme release, endothelial cytotoxicity, etc.). We and others have shown that C-ANCA can also directly activate HUVEC, but the precise target on HUVEC is unknown. We show in this study that C-ANCA recognize various targets on the HUVEC membrane (different from PR3 in our model), leading to secondary cell activation. Polyclonal affinity-purified C-ANCA recognized targets on the unfixed endothelial membrane in fluorescent ELISA, flow cytometry, and immunoprecipitation studies. C-ANCA did not react with Fcgamma receptors. Reverse transcriptase-polymerase chain reaction (RT-PCR) experiments showed that HUVEC did not express PR3. The targets of polyclonal and monoclonal anti-PR3 antibodies on the endothelial membrane were not the same. Some epitopes were lost after trypsin-EDTA digestion and formaldehyde fixation of cells, whereas anti-PR3 targeted unfixed HUVEC. This suggests that anti-PR3 react with the endothelial membrane and recognize conformational epitopes shared with PR3. Endothelial cells may thus participate in the inflammation associated with Wegener's granulomatosis and contribute to the emergence of clinical manifestations.

Clinical usefulness of antibodies to U1snRNP proteins in mixed connective tissue disease and systemic lupus erythematosus

OBJECTIVES

To determine whether the anti-68 kDaU1snRNP antibody is associated with mixed connective tissue disease and not with SLE; to evaluate correlations between anti-U1snRNP titers and disease activity; and to look for associations between anti-U1snRNP specificities and specific clinical features.

PATIENTS AND METHODS

40 patients with a positive double diffusion test for anti-68 kDa U1snRNP were studied, including 21 with mixed connective tissue disease, 14 with systemic lupus erythematosus and five with other connective tissue diseases. IgGs to 68 kDa U1snRNP were assayed using an ELISA. Clinical features, disease activity and antibody test findings were evaluated longitudinally in nine patients.

RESULTS

Both proportions of patients with anti-68 kDa U1snRNP and titers of IgG to 68 kDa U1snRNP were similar in the mixed connective tissue disease and systemic lupus erythematosus groups. Patients with mixed connective tissue disease were significantly more likely to have anti-A U1snRNP or anti-C U1snRNP than those with systemic lupus erythematosus (P < 0.03 and P < 0.04, respectively). No significant correlations were found between any of the features of mixed connective tissue disease (e.g., Raynaud's phenomenon, myositis, or sausage digits) and a specific anti-U1snRNP antibody. During follow-up (mean, seven years; range, 1-25 years), changes occurred in the anti-U1snRNP profile and in the anti-68 kDa U1snRNP titer. These changes were not correlated with disease activity.

CONCLUSIONS

IgGs to 68 kDa U1snRNP are not associated with a specific pattern of anti-RNP-positive connective tissue disease. No useful information can be gained by monitoring anti-68 kDa U1snRNP IgG titers over time. A Western blot profile including anti-A U1snRNP or anti-C U1snRNP indicates a high likelihood of U1snRNP-associated mixed connective tissue syndrome (MCTD).

[ANCA (antineutrophil cytoplasmic antibodies). Contribution of ANCA to the understanding of pathogenic mechanisms of systemic vasculitis]

ANCA (antineutrophil cytoplasmic antibodies) are a growing class of interest; these antibodies target lysosomial enzymes from polymorphonuclear cells. They represent diagnosis tools and prognosis markers in systemic vasculitis (Wegener's granulomatosis and microscopic polyangiitis). They are also detected in other chronic inflammatory diseases as lupus and rheumatoid arthritis. Their description, ten years ago, led to a huge amount of clinical and experimental work. The role of ANCA as pathogenic auto-antibodies in the disease is supported in numerous studies giving new insights into the pathogenesis of systemic vasculitis.

[Extra-articular manifestations of rheumatoid polyarthritis]

Rheumatoid arthritis is mainly a chronic and disabling articular disease. If most patients do well (because of limited form or efficient treatment), in some cases they present with extra-articular rheumatoid arthritis. The clinical manifestations of extra-articular rheumatoid arthritis are wide, ranging from common and benign manifestations such as rheumatoid nodules to severe events such as Felty's syndrome or systemic vasculitis. The incidence of systemic rheumatoid arthritis seems cumulative over the course of the chronic disease, and the severity of individuals lesions when fully developed can be of major importance and even life threatening. A classification of the main features of extra-articular rheumatoid arthritis is given (even if not perfect), and the clinical manifestations are described.

Antibodies to proteinase-3 mediate expression of intercellular adhesion molecule-1 (ICAM-1, CD 54)

We investigated the role of intercellular adhesion molecule-1 (ICAM-1) in the adhesion of polymorphonuclear neutrophils (PMN) to classic antineutrophil cytoplasmic antibody (C-ANCA)-treated endothelial cells, independently of cytokines. Human umbilical vein endothelial cells (HUVEC) grown to confluence in cytokine-free conditions were stimulated with C-ANCA sera and affinity-purified anti-proteinase 3 antibodies (PR3) from Wegener's granulomatosis (WG) patients. Non-activated PMN were added to treated HUVEC and adhesion was measured. In parallel experiments, treated HUVEC were fixed and ICAM-1 and E-selectin were assayed by cyto-ELISA; in other experiments anti-ELAM-1 and anti-ICAM-1 antibodies were assessed. In this in vitro model, adhesion of non-activated PMN to anti-PR3-stimulated HUVEC was enhanced. Adhesion was greater with anti-PR3 antibodies than with control and normal immunoglobulins, and correlated with the level of anti-PR3 antibodies. Neutralization of anti-PR3 antibodies by neutrophil azurophilic granule proteins abolished adhesion. This adhesion increased at the fourth hour after simulation, peaked at the twelfth hour and then decreased. This phenomenon occurred mainly through endothelial expression of ICAM-1 (the main counter-receptor for integrins, involved in firm PMN adhesion and migration) and E-selectin on HUVEC membranes. Anti-adhesion molecule antibodies inhibited this adhesion. This work supports the hypothesis of a direct effect of C-ANCA in endothelial stimulation, namely, on endothelium-PMN adhesion, and strengthens the major role of ICAM-1, directly involved in firm sticking of PMN to HUVEC, besides E-selectin. C-ANCA upregulate endothelial adhesiveness and thus participate in inflammatory reactions by providing endothelial adhesive structures for neutrophils. This might be one of the first steps leading to clinical expression of the disease. These results provide new insights into the pathogenesis of C-ANCA-related diseases.

Serum sickness after wasp venom immunotherapy: clinical and biological study

We describe a case of a man who developed serum sickness during wasp venom immunotherapy. Remarkable features were unusually severe neurological symptoms, multiple relapses in the absence of rechallenge, parallel course between clinical symptoms, serum levels of specific reagins and their antibodies, and a dramatic response to plasma exchange therapy. Desensitization is widely used and can cause a wide range of adverse effects; however, systemic vasculitis is a very rare complication and we are not aware of any case similar to ours, with serum sickness after injection of highly purified hymenoptera antigen. Clinicians should be aware of such a possibility.

Systemic sclerosis and sarcoidosis, a report of five cases

We report on five cases of associated systemic sclerosis and sarcoidosis (associated connective tissue diseases). The special peculiarities of this association are emphasized with a review of the literature (14 other cases reported). The clinical aspects, the prognosis, the role of silica, the likelihood of a chance association and the need (in our opinion) to reconsider the name 'sarcoidosis' are discussed.

[Systemic scleroderma and sarcoidosis: 3 new cases]

We observed 3 patients with successive scleroderma (SS) and (what is considered to be) sarcoidosis (SA). The diagnosis SS included in the 3 patients: Raynaud's syndrome with pulpal necrosis and capillaritis, sclerodactylia and acro-osteolysis, multiple joint pain and FAN+. Also observed were: esophagus involvement (n = 3), pulmonary artery hypertension (n = 1), telangiectasia (n = 2) and anti-Scl 70 (n = 2). Initially, all patients had restrictive pulmonary disease. SS was diagnosed 5 to 9 years prior to SA in 2 patients. Diagnosis of SA was based on the following arguments: Loëfgren's syndrome with erythema nodosa (n = 1), parotiditis (n = 2), sicca syndrome (n = 2), myalgia (n = 2), joint involvement (n = 2), non-infectious pluropericarditis (n = 2), epitheloid and giant cell granulomas without caseous necrosis (lung = 3, liver = 1, lymph nodes = 1, salivary glands = 1, synovia = 1), negative search for bacilli, elevated conversion enzyme (n = 1) and, in each case, by the lack of any other cause. One patient died from lung cancer and another from respiratory failure. Nome of the patients had primary biliary cirhosis. This rare association between SS and SA demonstrates the confluent limits of certain systemic diseases and raises a difficult problem to differentiate pulmonary involvement in these diseases. The gravity of this localization and the poor sensitivy to corticosteroids.

Ossification of the posterior longitudinal ligament, diffuse, idiopathic skeletal hyperostosis, abnormal retinol and retinol binding protein: a familial observation

We describe a 52-year-old man who presented with diffuse idiopathic skeletal hyperostosis, ossification of the posterior longitudinal ligament, and abnormal levels of retinol and retinol binding protein (RBP). The molar retinol/retinol binding protein ratio was high, suggesting congenital functional RBP deficiency. His two sons, aged 23 and 27 years, shared the same biological abnormality without clinical symptoms. To our knowledge, this is the first case report of such a familial association.

Familial multiple myeloma. Report of a case in a father and daughter. Review of the literature

We report a case of familial multiple myeloma in a father and daughter. The same lambda chain was detectable in both patients. Symptom onset occurred three years earlier in the daughter than in the father. We found 52 previously published cases of familial myeloma, of which only 13 occurred in a parent and child. Given the incidence of myeloma in the general population, the occurrence of several cases in the same family is probably not due to chance. The few available data on karyotypes and oncogenes are discordant. The respective role of genetic factors and environmental factors is discussed.

Angiotropic large cell lymphoma with mononeuritis multiplex mimicking systemic vasculitis

Angiotropic large cell lymphoma (ALCL), the so-called malignant angioendotheliomatosis, is characterised by proliferation of tumorous cells within small vessels. Manifestations in the CNS and cutaneous lesions prevail in the clinical presentation, although any organ can be involved. The recent classification of this lymphoma as part of the large cell lymphomas has modified the therapeutic approaches employed. This should improve the prognosis of this usually fatal disease. An unusual case presenting with fever, mononeuritis multiplex, and cutaneous lesions is reported. Peripheral neuropathy without other neurological symptoms is uncommon, and, to our knowledge, such isolated mononeuritis multiplex with nerve lesions has not been previously reported in ALCL. The clinical diagnosis was a systemic necrotising vasculitis and it is considered that its differential diagnosis must include angiotropic large cell lymphoma.

Interleukin 6 secretion by monocytes and alveolar macrophages in systemic sclerosis with lung involvement

Interleukin-6 (IL-6) has been involved in the pathogenesis of inflammatory and/or autoimmune diseases. We characterized the production of IL-6 by blood monocytes and alveolar macrophages (AM) in 11 patients with definite systemic sclerosis (SSc) with lung involvement and in eight normal control subjects. IL-6 levels were determined in serum, bronchoalveolar lavage (BAL) supernatants, monocytes, and AM cell culture supernatants using an ELISA kit. BAL cell analysis evidenced an alveolitis with hypercellularity and increased neutrophils and mast cells absolute counts. Serum and BAL IL-6 levels were low and similar in SSc and control groups. The monocytes of the group with SSc secreted more IL-6 than did the control group, both spontaneously (p = 0.01) and after LPS stimulation (p = 0.0007). Spontaneous secretion of IL-6 by AM tended to be higher in the SSc group than in the control group (p = 0.22). LPS-induced IL-6 secretion by AM was similar in both groups. Our study demonstrates that during SSc lung disease, spontaneous and stimulated IL-6 secretion by blood monocytes is increased, compared with secretion by healthy control subjects. By contrast, IL-6 secretion by AM is normal despite evidence of mild alveolitis.

Pneumocystis carinii pneumonia in the course of connective tissue disease: report of 34 cases

OBJECTIVE

To determine the circumstances, the clinical features and the outcome of Pneumocystis carinii pneumonia (PCP) in human immunodeficiency virus (HIV)-free patients with connective tissue diseases (CTD).

METHODS

Retrospective analysis of all cases referred 10 medical units in the last 10 years.

RESULTS

A total of 34 cases of PCP in patients with CTD were studied (Wegener's granulomatosis, n = 12; systemic lupus erythematosus, n = 6; polyarteritis nodosa, n = 4; poly/dermatomyositis, n = 5; others, n = 7). The majority of patients (25/34 patients; 74%) presented PCP during the first 8 months following the diagnosis of CTD. At the time of diagnosis of PCP, most patients (32/34; 94%) were receiving corticosteroids (mean prednisone equivalent dose: 1.2 mg/kg/day) associated in 24 cases with cytotoxic agents (cyclophosphamide, n = 19; methotrexate, n = 5). Most patients were lymphocytopenic at the onset of PCP: 91% (31/34) of patients had fewer than 1.5 x 10(9)/l circulating lymphocytes and 76% (26/34) had fewer than 0.8 x 10(9)/l. The mean duration of prodromal symptoms was 6 days: this is much shorter than for AIDS associated PCP. Half the patients required intensive care for respiratory failure. Mortality was high (11/34 patients; 32%) although deaths were partly due to infections acquired in intensive care units. Among the 23 survivors, 10 (43%) received secondary prophylaxis for PCP and 13 (57%), received the usual therapeutic regimen. No relapse has been observed in either group with a mean followup of 22 months.

CONCLUSION

Although rare, PCP must be considered in patients with any type of CTD and receiving cytotoxic agents and corticosteroids, particularly if they are lymphocytopenic. Thus, bronchoalveolar lavage must be rapidly performed in patients with CTD presenting with fever, pulmonary infiltrates, hypoxemia and lymphopenia.

[Failure of intravenous immunoglobulins in certain systemic diseases. 5 cases]

Human polyvalent immunoglobulins administered intravenously have shown to be effective in some immune diseases. We administered high dose-IV Ig (2g/kg/session) in five patients with severe chronic systemic diseases. Their condition did not improve, except in one case where a transient response was noticed. Considering the inconsistent results and high cost of IV Ig, double blind studies are required to determine the conditions in which high dose IV Ig may be more effective than conventional treatments.

Sulphasalazine-related life-threatening side effects: is N-acetylcysteine of therapeutic value?

This report is on a patient with a spondylarthropathy with peripheral joint involvement treated with sulphasalazine who developed severe hepatitis, disseminated intravascular coagulation, high spiking fever, a mononucleosis-like syndrome and a diffuse cutaneous rash. All these features resolved rapidly after drug withdrawal and intravenous N-acetylcysteine. Serious sulphasalazine-related adverse reactions are rare and their outcome is generally favourable within a few weeks after drug withdrawal. However, certain cases with life-threatening side effects may need additional treatment. The course in our patient suggests that N-acetylcysteine may be useful for treating sulphasalazine-induced side effects.

Hypocomplementemic urticarial vasculitis syndrome, Jaccoud's syndrome, valvulopathy: a new syndromic combination

We describe 3 cases of hypocomplementemic urticarial vasculitis syndrome (HUVS) with Jaccoud's hands deformity and cardiac valve disease (aortic regurgitation, mitral regurgitation, mitral disease). In one case, the valve lesions required valve replacement and later a heart transplant. Valve disease and articular deformities developed 2 and 4 years, respectively, after the onset of HUVS. This as yet undescribed combination of diseases suggests a new syndrome. Pathogenesis of periarticular and cardiac lesions is unknown. The role of Clq and anti-Clq antibody is discussed.

Lupus mastitis heralding systemic lupus erythematosus with antiphospholipid syndrome

Lupus mastitis is an infrequent dermatologic disease. We describe a case of bilateral lupus mastitis heralding a severe systemic lupus erythematosus with the antiphospholipid syndrome.

[Still disease in the adult and in pregnancy]

The interactions between pregnancy and adult-onset Still's disease are unclear. Nine pregnancies which occurred from 1983 through 1991 in seven women (mean age 27.7 years; range 23-40) were studied retrospectively. Five patients had one pregnancy and two had two pregnancies. Onset of the joint disease occurred before or during pregnancy. The joint disease occurred at the 5th or 6th month of the first pregnancy in two patients; one of these patients had a second pregnancy which was not associated with a flare. In five patients, onset of the joint disease occurred 4, 15, 42, 44 and 58 months before the first pregnancy, respectively; any effects of the joint disease on the pregnancy were extremely variable. 6 infants were full-term and two were premature (35 weeks); the remaining pregnancy was electively terminated; Apgar scores were normal in all eight infants, who were all male. Adult-onset Still's disease did not influence the outcome of the pregnancy in our patients; no clear-cut effects of pregnancy on adult-onset Still's disease were seen.

Seven Achilles tendinitis including 3 complicated by rupture during fluoroquinolone therapy

We describe 7 Achilles tendinitis occurring during fluoroquinolone treatment. Antibiotic agents used were pefloxacin and ofloxacin. In 3 cases the course was complicated by rupture of the tendon, one of which is histologically documented. The toxic effects of quinolones on tendon is discussed.

[Post-traumatic psoriatic rheumatism. Clinical and medico-legal aspects]

The possibility that injury may play a role in the development of some forms of chronic inflammatory rheumatic disease has been a subject of debate for many years. Such a role is accepted for some cases of rheumatoid arthritis, remains controversial for spondylarthropathies, and is poorly understood in psoriatic arthritis. Three cases of post-traumatic psoriatic arthritis are reported herein. The difficulty of establishing the causative role of the injury (despite precise criteria) is underlined, the pathophysiologic mechanism is discussed (deep Koebner phenomenon?), and possible legal consequences are reviewed.

[3 cases of polyarthritis treated with recombinant alfa interferon]

Bilateral symmetrical polyarthritis occurred in three patients (2 males and 1 female), with no previous history of inflammatory rheumatologic disease, given alpha-interferon for 1 1/2, 7, and 10 months as treatment of chronic non A-non B hepatitis, myelofibrosis, and thrombocytopenia with myeloproliferative disorder, respectively. Joint manifestations developed 1 1/2, 3, and 10 months after initiation of alpha-interferon in a dosage of 3.10(6) U three times a week, 4.5.10(6) U per day, and 8.10(6) U three times a week. Polyarthritis persisted following withdrawal of alpha-interferon in the two last patients of whom one had rheumatoid nodules and positive rheumatoid serology and the other had scleritis, exanthema, and negative rheumatoid serology. Erosive rheumatoid arthritis was diagnosed after 28 months and 12 months, respectively, in two patients who required systemic corticosteroids with antimalarials (1 case) or azathioprine after failure of methotrexate (one case). Follow-up in the third case (12 months) is too short to allow differentiation of systemic lupus erythematosus (ANA: 1/1500 H with anti-DNA antibodies 58 U/ml) and chronic autoimmune hepatitis. Reports of chronic inflammatory rheumatologic disease during alpha interferon therapy are exceedingly few in number. In the cases reported herein, alpha-interferon may have either triggered or revealed the joint disease. To prevent occurrence of this complication, exclusion from alpha-interferon therapy of patients with autoantibodies or a positive history for clinical evidence of immune dysfunction may be considered.

Takayasu's arteritis associated with Still's disease in an adult

We report a new case of association between adult Still's disease and Takayasu's arteritis (TA). This association is infrequent and raises again the controversy of the origin of Takayasu's arteritis.