Increased serum leptin levels are associated with metabolic syndrome and carotid intima media thickness in premenopausal systemic lupus erythematosus patients without clinical atherosclerotic vascular events

Aim To assess subclinical atherosclerosis and the role of inflammatory mediators, vascular endothelial cell activation markers and adipocytokines in systemic lupus erythematosus (SLE) in the presence or absence of metabolic syndrome (MetS). Methods We studied 66 premenopausal female SLE patients (20 with MetS) and 28 female healthy controls (HCs) without history of cardiovascular disease (CVD). Subclinical atherosclerosis was screened by measuring carotid intima media thickness (CIMT). Serum levels of high sensitivity C-reactive protein (hs-CRP), tumour necrosis factor α (TNFα), interleukin 6 (IL-6), soluble intercellular adhesion molecule 1 (sICAM-1), soluble E-selectin, leptin and visfatin were measured. Results The mean age of MetS⁺SLE, MetS^- and HC were 38.3 ± 6.7, 32.7 ± 9.3 and 29.9 ± 5.6 years, respectively. The mean disease duration, SLICC (Systemic Lupus International Collaborating Clinics damage index) and Systemic Lupus Erythematosus Disease Activity Index scores were 74.8 ± 54.9 months, 0.16 ± 0.48 and 1.18 ± 1.5, respectively, and were similar between MetS⁺and MetS^- SLE patients. CIMT values were higher in both MetS⁺ and MetS^- SLE patients than HCs ( p < 0.001). sICAM-1 and erythrocyte sedimentation rate levels were higher in both MetS⁺ and MetS^- SLE patients than HCs ( p < 0.001; p = 0.002, p = 0.001). The SLE MetS⁺ group had higher CIMT values than SLE MetS^- (right: p = 0.003; left: p = 0.025). Leptin levels and homeostatic model assessment (HOMA) scores were significantly higher in SLE MetS⁺ than SLE MetS^- ( p = 0.018; p = 0.04). Leptin and CRP levels and body mass index, SLICC and HOMA scores were correlated with CIMT values (right: p = 0.03, p < 0.001, p < 0.001, p = 0.026 and p < 0.001, and left: p = 0.028, p = 0.03, p = 0.003, p = 0.002 and p = 0.025). Conclusions In premenopausal women with SLE without a history of CVD, CIMT values were increased and related to MetS. Leptin was increased in patients with MetS and correlated with CIMT values.

Favourable pregnancy outcome in Takayasu arteritis: a single-centre experience

OBJECTIVES

Takayasu arteritis is a chronic large-vessel vasculitis in young women of reproductive age. We aimed to obtain information on pregnancy in TA retrospectively.

METHODS

Takayasu arteritis patients with history of pregnancy were included in this study. The evaluations included physical findings, serum C-reactive protein, erythrocyte sedimentation rate as well as history and symptoms. Information about pregnancies, abortus, deliveries and newborns was obtained from medical records. Disease activity score, disease damage index appraised Kerr's criteria and vasculitis damage index (VDI) and medication were recorded.

RESULTS

Thirty-six Takayasu arteritis patients who had a total of 84 pregnancies were evaluated. The mean age of patients ranged 24.5 ± 6.6 years. Subclavian arteries (86%) were the most frequently involved vessels. We were able to complete the follow-up of ten patients who had a pregnancy after diagnosis during the period of pregnancy. Two patients who had renal artery involvement and active disease in third trimester suffered from preeclampsia and a worsening of hypertension. In one of them, disease flared up in the third trimester. There was no active disease in the postpartum sixth month. Maternal heart failure, cerebrovascular accident, death or cerebral hypoperfusion at the time of delivery, asphyxia and newborn anomalies were not seen in any of these patients.

CONCLUSIONS

TA pregnancies may have a favourable outcome with regular follow-up schedule and close monitorisation of blood pressure.

Expression of KIR and C-type lectin receptors in Behcet's disease

OBJECTIVE

Behçet's disease (BD) is a multisystemic disorder with a possible underlying pathology of immune-mediated vasculitis. Genetic susceptibility associated with HLA-B*51 and B*2702 has been implicated in its pathogenesis. Considering the recently defined regulatory mechanisms of NK cells through HLA class I binding receptors, we hypothesized that interactions of NK and T cells through the NK receptors may be important in the pathogenesis of BD.

METHODS

The impact of different expression patterns of HLA-recognizing receptors on NK or T cells was analysed in 51 patients with BD and 32 healthy controls. We used flow cytometry to investigate the expression of KIR3DL1 from the polymorphic killer immunoglobulin-like receptor (KIR) family, which binds a shared HLA-Bw4 motif on HLA-B51 and *2702 alleles, and CD94 from the conserved C-type lectin receptor family, which binds HLA-E. Thirty-three of the BD patients and 19 of the controls carried the same HLA-Bw4 motif.

RESULTS

CD3(+) T cells were increased in patients with BD compared with controls (81 vs 75%, P = 0.001), whereas the NK cells did not show any difference between the two groups. Increased expression of CD94 in BD was observed on CD16(+)CD56(+) cells (66 vs 57, P = 0.04) and on CD3(+) (7.7 vs 4.0, P < 0.001) and CD3(+)CD56(+) (44 vs 35, P = 0.02) T cells. KIR3DL1 expression on the NK and T cells was not statistically different between the two groups. No effect of HLA-Bw4 motif was observed on the expression of CD94 and KIR3DL1 in both the patients and the controls.

CONCLUSION

The absence of a correlation between KIR3DL1 expression and HLA-Bw4 motif confirms previous work reporting that the expression of these molecules is regulated separately. Increased expression of CD94 may suggest that NK receptors play a pathogenic or regulatory role in BD.

A weak association of HLA-B*2702 with Behçet's disease

This study aimed to analyse the association of HLA-B alleles other than -B51 with Behçet's disease (BD). We also investigated the frequency of HLA-B alleles sharing the same natural killer cell immunoglobulin-like receptor (KIR) binding sequence with HLA-B51. Broad-genotyping of HLA-B locus by PCR-SSOP in 174 Turkish BD patients and 191 healthy controls confirmed the strong association of B*51 with BD (60.9% in BD patients, 24.6% in healthy controls, OR = 4.78). No other HLA-B allele was identified showing an association with BD after adjusting for multiple testing or by using relative predispositional effects (RPE) analysis after the deletion of B*51. HLA-B alleles reacting with the sequence specific oligonucleotide probe 23, which corresponds to the KIR binding site of B*51, were found to be positive in 127 BD patients (73%) and 90 controls (47%) (OR = 3.03, 95% CI 2-4.7). The repeated RPE analysis after separating HLA-B alleles carrying B51-KIR binding sequence as distinct alleles within a broad-type allele group revealed B*2702 allele as the only allele showing an association with BD after the deletion of B*51. Selective increase of B*2702, the only B*27 allele carrying the same KIR binding sequence with B*51, warrants investigation of the possibility of interaction of HLA molecules with KIRs on NK or other T cells in the pathogenesis of BD.

Antiphospholipid antibodies and antiphospholipid syndrome in patients presenting with immune thrombocytopenic purpura: a prospective cohort study

The pathogenetic role and the clinical importance of the presence of antiphospholipid antibodies (APAs) in patients with immune thrombocytopenic purpura (ITP) are not clear. In this study, the prevalence and clinical significance of APAs were investigated in patients with ITP. Eighty-two newly diagnosed ITP patients were prospectively studied. They were evaluated for the presence of lupus anticoagulant (LA) and immunoglobulin G/M anticardiolipin antibodies (ACAs). Thirty-one patients (37.8%) were APA positive at diagnosis. No statistically significant differences were found between the APA-positive and APA-negative groups regarding gender, initial platelet counts, or response to methylprednisolone therapy. After 5 years of follow-up, cumulative thrombosis-free survival of APA-positive (n = 31) and APA-negative (n = 51) ITP patients was 39% and 97.7%, respectively. A significant difference was found between these groups by log-rank test (P =.0004). In addition, LA was an important risk marker for the development of thrombosis in ITP patients. After a median follow-up of 38 months, 14 ITP patients (45%) who had APA positivity developed clinical features (thrombosis or fetal losses) of antiphospholipid syndrome (APS). There were no differences between the APA-positive patients with and without APS regarding the initial platelet counts, response to the therapy, or ACA positivity. The positivity rate for LA was significantly higher in those patients with ITP who developed APS (chi(2): P =.0036; relative risk 7.15; 95% confidence interval, 1.7-47). In conclusion, this study indicates that a significant proportion of patients initially presenting with ITP and APA positivity developed APS. In patients with ITP, the persistent presence of APAs is an important risk factor for the development of APS.

Familial aggregation of Behçet's disease in Turkey

OBJECTIVE

Familial aggregation of Behçet's disease has been reported previously. The current study aimed at investigating the sibling recurrence risk ratio (lambda s) for Behçet's disease, which is of value in the estimation of the magnitude of genetic factors in the pathogenesis of Behçet's disease.

METHODS

170 consecutive unrelated index cases (98 male, 72 female) were interviewed with a detailed questionnaire to ascertain their family trees and the manifestations of Behçet's disease in their relatives. Subsequently, the immediately older sibling, or if an older sibling was not available, the immediately younger sibling, was selected as the second sibling for the evaluation. These siblings were contacted by telephone, and all subjects with recurrent oral ulcers were invited for examination.

RESULTS

31 of the 170 index cases had 51 relatives fulfilling the International Study Group criteria. Among 166 second siblings, seven had Behçet's disease (six male, one female) and 22 siblings (eight male, 14 female) with recurrent oral ulcers were identified. Sibling recurrence rate-defined as the ratio of the risk of being affected among the siblings of patients and the risk of being affected in the general population- was found to be 4.2%, which gives a lambda s value for Behçet's disease of between 11.4 and 52.5 in Turkey.

CONCLUSIONS

A high lambda s value supports a strong genetic background for Behçet's disease which will be helpful in designing genetic linkage studies.

The use of two different Health Assessment Questionnaires in Turkish rheumatoid arthritis population and assessment of the associations with disability

The aim of this study was to compare and evaluate the Health Assessment Questionnaire (HAQ) and Arthritis Impact Measurement Scale (AIMS) in our patient population with rheumatoid arthritis (RA) and also to find some associations with clinical assessment of disability. One hundred and twenty-three consecutive adult patients with RA were included in the study. Pain, and global assessments by patients and physicians were recorded using a 10 cm visual analogue scale. Each patient completed the HAQ and AIMS questionnaires. Correlations among tender and swollen joint counts, erythrocyte sedimentation rate, pain, and AIMS anxiety and depression scores were all investigated. Pearson correlation was used to assess the possible correlations between each questionnaire and clinical variables. Pain and the AIMS subscales of mobility, dexterity, social activity and activities of daily living correlated with global assessments by patients and physicians, and tender joint counts. Depression correlated with pain and disability (HAQ). It was also of note that we observed high intercorrelation between the global assessments of physicians and patients. It was concluded that a measure of functional status, patient global assessment and pain score should be considered as important in the evaluation of RA patients. Measuring psychological well-being also provides further information. The HAQ, with the addition of the anxiety and depression sections of AIMS (CLINHAQ), provides the advantage of a global evaluation of these chronically ill patients.

Anti-beta2-glycoprotein I, anti-prothrombin and anticardiolipin antibodies in a longitudinal study of patients with systemic lupus erythematosus and the antiphospholipid syndrome

OBJECTIVE

To determine anti-beta2 glycoprotein-I (anti-beta2GPI) and anti-prothrombin (anti-ProT) antibody levels, and the IgG subclass distribution of anti-beta2GPI antibodies, in serial samples from patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) having initial or recurrent thrombotic/neurological (T/N) events during the study period. To investigate the correlations between these antibodies and beta2GPI antigen, anticardiolipin antibody (aCL), anti-double-stranded (ds) DNA, C3 levels and disease activity.

METHODS

Fifty serum samples were identified from seven patients with SLE who had had T/N events during the follow-up from a cohort under long-term follow-up. IgG anti-beta2GPI, anti-ProT, aCL, IgG subclasses of anti-beta2GPI and beta2GPI antigen levels were determined by ELISA. Corresponding disease activity [British Isles Lupus Assessment Group (BILAG)], anti-dsDNA and C3 levels were compared.

RESULTS

IgG anti-beta2GPI antibody levels were elevated in six of the patients before and after the T/N events with less marked fluctuations than aCL antibody levels. The predominant subclass of anti-beta2GPI antibodies was IgG2 before and after the T/N events. IgG anti-ProT antibodies were negative in all cases. There was a significant but weak correlation between anti-beta2GPI and aCL antibodies. No correlation was found between disease activity and IgG anti-beta2GPI antibody and beta2GPI antigen levels. There were fluctuations in beta2GPI antigen levels and a trend to increase after T/N events was observed in some patients.

CONCLUSION

Most of the patients with a T/N event during the study period had IgG anti-beta2GPI, but not IgG anti-ProT antibodies. Many IgG aCL-negative samples were found to have IgG anti-beta2GPI activity during the follow-up period. The predominant subclass of IgG anti-beta2GPI was IgG2, which may have importance in the pathogenesis of APS. beta2GPI antigen levels were found to be increased in some patients with SLE after T/N events. IgG anti-beta2GPI antibodies may be used as an adjunctive marker of future T/N events in patients with SLE and APS with aCL antibodies and lupus anticoagulant.

beta 2-Glycoprotein I and anti-beta 2-glycoprotein I antibodies: where are we now?

beta 2-Glycoprotein I (beta 2-GPI), a plasma protein with in vitro anticoagulant properties, has been recognized to have an important role in the antiphospholipid syndrome (APS) as a cofactor and an (co)antigen in ELISA assays. Although beta 2-GPI levels were found to be increased in some patients with APS, the clinical value of measuring beta 2-GPI levels in APS is not known. Several reports have suggested that anti-beta 2-GPI antibodies may be a marker for the APS and might be more specific for the vascular complications of the APS than anticardiolipin antibodies. There have been major discoveries about phospholipid (PL) and antibody binding sites on beta 2-GPI, although more studies are needed. Reports of changes in cell membrane PL composition or exposure of other anionic molecules by apoptosis, cell activation and oxidative injury suggest mechanisms to explain beta 2-GPI binding and the generation of cryptic epitopes for aPL/anti-beta 2-GPI antibodies.

Coagulation factor V gene mutation increases the risk of venous thrombosis in behçet's disease

We investigated the prevalence of the coagulation factor V gene G1691A mutation in 64 patients with Behçet's disease (BD) and in 107 apparently healthy individuals. The mutation was present in the heterozygous state in 37.5% of the patients with a history of deep vein thrombosis (12/32) and in 9.4% of the patients without any thrombotic event (3/32). Eleven healthy individuals were also heterozygous for the mutation (10.3%). The prevalence of the mutation in BD patients with and without thrombosis was significantly different (P = 0.0079). We conclude that the factor V gene mutation may play a major role in the development of venous thrombosis in BD.

Antibodies reactive with HIV-1 antigens in systemic lupus erythematosus

Antibodies reactive with retroviral gag proteins have been detected in patients with systemic lupus erythematosus (SLE). We investigated the immune responses against human immunodeficiency virus (HIV) 1 antigens in the sera of 44 Turkish patients with SLE. Serum samples were tested by using two different commercial enzyme immunoassay (EIA) kits and by Western blotting. EIA studies revealed positive results in 12 patients (27%) for HIV-1 antigens by one of the kits that coated with purified viral antigens. Immunoblot analysis showed antibodies mainly to retroviral gag proteins in 23 patients (52%). The most frequent reactivity was against the p18 gag protein (n = 9). Although antibodies reactive particularly with p24 antigen were described in the previous reports, antibodies to p24 were found in only two patients. These findings might reflect a serologic diversity in different ethnic groups and also suggest the involvement of different triggers in the etiopathogenesis of SLE.

Primary antiphospholipid syndrome associated with mesenteric inflammatory veno-occlusive disease

We describe a 24-year old Caucasian man with gangrene of small bowels and intestinal resection due to mesenteric inflammatory veno-occlusive disease (MIVOD) who later developed deep vein thrombosis in his left leg. He had no clinical evidence of an underlying symptomatic connective tissue disease or Behçet's disease. An IgG anticardiolipin antibody titre above 60 GPL unit/mL and thrombocytopenia confirmed the diagnosis of primary antiphospholipid syndrome (APS). This is the first known case of APS associated with MIVOD.

Female genital tract giant cell arteritis associated with occult temporal arteritis

Giant cell arteritis (GCA) of the female genital tract has been described as an incidental finding, but associated temporal arteritis (TA) has been rarely reported. We describe a case of female genital tract GCA associated with occult giant cell TA, which in the absence of cranial symptoms was confirmed by a random temporal artery biopsy. The patient remains asymptomatic at 12 month followup after treatment with prednisolone and azathioprine.

Comparative study of the skin pathergy test with blunt and sharp needles in Behçet's disease: confirmed specificity but decreased sensitivity with sharp needles

OBJECTIVE

To compare the specificity and sensitivity of the skin pathergy test performed with blunt and sharp needles in patients with Behçet's disease.

METHODS

The skin pathergy test was performed using the simultaneous four needle prick method with blunt and sharp, thick and thin needles in 92 patients with Behçet's disease, 64 healthy controls, and 128 patients without Behçet's disease. The test was evaluated at 48 hours.

RESULTS

No positive skin pathergy test was found in healthy controls and patients without Behçet's disease. The frequency and intensity of the positive skin pathergy test with blunt needles were significantly higher than those with sharp needles.

CONCLUSION

This study reconfirmed the specificity of a positive skin pathergy test for Behçet's disease using blunt and sharp needles and showed a decreased sensitivity and intensity of the reaction with sharp needles.

Overproduction of monocyte derived tumor necrosis factor alpha, interleukin (IL) 6, IL-8 and increased neutrophil superoxide generation in Behçet's disease. A comparative study with familial Mediterranean fever and healthy subjects

OBJECTIVE

The etiopathogenesis of Behçet's disease (BD) has not yet been clarified but might involve immune dysfunction. As cytokines are involved in the regulation of immune responses and inflammatory reactions, we investigated whether they may play a role in the pathogenesis of BD.

METHODS

We investigated spontaneous and lipopolysaccharide (LPS) stimulated production of tumor necrosis factor alpha (TNF alpha), interleukin (IL) 1, IL-6, IL-8 and granulocyte monocyte macrophage colony stimulating factor (GM-CSF) by peripheral blood monocytes from 21 patients with BD, 10 healthy controls and 10 patients with familial Mediterranean fever (FMF), another chronic inflammatory disease. We also studied superoxide generation and surface antigen expression by polymorphonuclear neutrophils (PMN).

RESULTS

The spontaneous secretion of TNF alpha, IL-6 and IL-8 by monocytes was significantly increased in patients with active BD. The secretion of TNF alpha, IL-1, IL-6 and IL-8 was found to be in normal range in asymptomatic patients with FMF. The LPS stimulated production of TNF alpha, IL-6, IL-1 and IL-8 was significantly increased in patients with BD, without any correlation with BD activity. In vitro, PMN spontaneously generated significant amounts of superoxide in patients with active BD.

CONCLUSION

Taken together, our results suggest that monocyte and PMN dysfunctions may play a role in the pathogenesis of BD.

[Behçet's disease: a cause of hemoptysis]

Behçet's disease should be considered in the differential diagnosis of haemoptysis. Pulmonary manifestations of Behçet's disease, which are due to the vasculitis of pulmonary vessels are quite rare. 8 cases who presented with haemoptysis and subsequently diagnosed as Behçet's disease will be presented. The value of diagnostic methods will be discussed. All patients yielded other manifestations of vasculitis such as aphtous stomatitis, genital ulcerations, cutaneous lesions, iridocyclitis and thrombophlebitis. Chest X-ray films yielded unilateral hilar enlargement in 3, unilateral elevation of diaphragm in 3, round and nonhomogenous opacities in 4 of 8 patients. Thorax CAT was performed in 5 of whom 4 showed aneurysms and irregularities of vessel walls. Pulmonary angiography of 2 patients displayed aneurysm and thrombosis. Perfusion defects of various sizes were evident in 7 patients obtained by pulmonary perfusion scans.