AB0558 PREVALENCE OF LATENT TUBERCULOSIS INFECTION AND ITS ASSOCIATIONS WITH CLINICAL AND SEROLOGICAL PARAMETERS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic Lupus Erythematosus (SLE) and Tuberculosis are complicatedly related and studies have shown increased risk of TB in SLE. Studies of Latent TB and SLE are inadequate. This study intended to assess the prevalence of latent TB and its association with disease parameters in SLE.

Objectives

To assess the prevalence of latent TB in patients with SLE. To investigate the demographics and clinical characteristics in patients with SLE and concomitant latent TB compared to those without.

Methods

This is a single center cross sectional study. 124 adult patients with SLE without past h/o TB were recruited. SLE demography, disease activity indices, autoantibody profile and steroid use were noted. Presence of Latent TB infection was assessed in all patients based on the IFN-g release assay (TB-IGRA). Based on the results of IGRA, SLE cases were divided into 2 groups-IGRA positive and IGRA negative. The collected parameters were compared between the 2 groups.

Results

Among 124 patients, 19 had latent TB resulting in a point prevalence of 15.4 %. The average disease duration was 4.3 years in IGRA positive and 4.6 in IGRA negative group(p>0.05). Among antibody profile, though no statistical significance among the groups, proportion of antibodies like anti Ku, Ro 60, Ro 52 and La were numerically higher in the IGRA positive group (21.1%, 42.1%, 42.1% and 21.1% respectively) when compared to the IGRA negative group (11.5%, 28.8%, 28.1% and 7.7% respectively). Likewise, anti nucleosome, histone, U1RNP, PCNA, aCLA IgG and IgM, beta 2 GPI IgG and LAC were numerically higher in IGRA negative group (42.3%, 40.4%, 43.3%, 8.7%, 23%, 18.3%, 28.8%, 14.4%) when compared to IGRA positive group (31.6%, 21.1%, 31.6%, 0, 15.8%, 5.3%, 15.8%, 5.3%). Mean clinical SLEDAI was 2.37 ±5.1 in IGRA positive and 3.5 ±5.77 in IGRA negative group. Among clinical features, 1 person in IGRA positive and none in the IGRA negative group had current gastrointestinal involvement. Comparison of other organ manifestations yielded no statistically significant difference in the 2 groups at this point. Serology revealed greater proportion of C4 in IGRA negative as compared to the positive group(p<0.042).

Conclusion

Prevalence of latent TB in SLE cases was 15.4%. Although comparison of demographic, clinical and autoantibody profile did not yield any statistically significant differences, the early turnover from this pilot study mandates further evaluation with larger sample size.

Table 1.

Comparison of clinical and laboratory parameters between IGRA positive and IGRA negative SLE cases

IGRA POSITIVE(n=19)IGRA NEGATIVE(n=105)p VALUEAge(Mean± SD)31.79±9.729.26 ±10.80.199Female Sex n(%)19(100)101(97.1)0.312Anti P0 antibody n(%)3(15.8)14(13.5)0.827Anti Ribo P antibody n(%)2(10.5)13(12.5)0.761Age of disease onset(Mean± SD)25.58± 10.624.62± 10.570.285Disease duration(Mean± SD)4.33 ±4.024.6± 3.530.438Treatment duration(Mean± SD)3.84± 4.124.03± 3.420.439Clinical SLEDAI(Mean± SD)2.37 ±5.13.5 ±5.770.306SLICC ACR DI(Mean± SD)0.105±0.320.231± 0.660.666Current CNS involvement1(5.3)4(3.8)0.781Current renal involvement3(15.8)26(25)0.367Current hematological involvement1(5.3)14(13.5)0.272Current GI involvement1(5.3)00.052Current steroid dose(Mean± SD)11.32± 11.6513.03 ± 11.60.400Serum C3(Mean± SD)0.79 ±0.320.89± 0.470.477Serum C4(Mean± SD)0.19± 0.0720.1635± 0.130.413Anti dsDNA (Mean± SD)458± 400.8379.5± 400.50.454Low C3 n(%)9(52.9)37(38.9)0.108Low C4 n(%)2(11.8)35(36.8)0.042Elevated Antidsdna n(%)6(35.3)37(38.9)3.343

Disclosure of Interests

None declared

POS0775 COMBINED MODEL OF RENAL HISTOPATHOLOGY AND CLINICAL PARAMETERS BETTER PREDICT ONE YEAR RENAL OUTCOMES IN LUPUS NEPHRITIS: ANALYSIS OF 334 KIDNEY BIOPSIES

Background

Diagnosis of Lupus Nephritis (LN) is currently based on laboratory tests and renal histopathology. Role of histopathological features in determining long term outcomes is unclear.

Objectives

1. To assess if clinical and biochemical parameters at baseline can identify renal histopathological class.

2. To assess the clinico-histopathological predictors of renal response.

Methods

This is a single centre retrospective study comprising 334 LN renal biopsies. Clinical and biochemical parameters at the time of biopsy were noted and their association with histopathological class, activity and chronicity scores (AS/CS) (ISN/RPS classification) were evaluated. Complete, partial or no response (CR, PR, NR) for renal outcome (EULAR/EDTA) at 1 year were assessed for 293 patients. Binary logistic regression was done to look for the predictors of NR.

Results

Class III/IV LN was seen in 240(71.8%). Hypertension was seen in (52.1%) of class III/IV and <25% each with class II, V and combined class(p<0.001). Class III/IV had lower eGFR [87.6(62.75-118.8)] (p<0.001) than the other classes. Nephrotic range proteinuria was seen in 32% of class V and 21% in class III/IV (p=0.004). Among class-III/IV, AS had weak correlation with baseline UPCR (r=0.31) and eGFR (r=-0.172) (p<0.01). CS had weak negative correlation with eGFR (r=-0.212, p<0.01). NR at 1 year was higher in males (OR-4.6,95%CI-1.9-10.8, p<0.001), those with abnormal serum creatinine (OR-3.3,95%:CI1.6-7.02, p-0.001), higher renal SLEDAI (p<0.05), higher AS, CS (p<0.001), interstitial inflammation and tubular atrophy(p<0.005) (Table 1). On binary logistic regression a combined clinico-histopathological model comprising of serum creatinine, UPCR, male sex and CS performed best in predicting NR (Figure 1).

Table 1.

Comparison of baseline characteristics among those who attained any response (CR/PR) versus others at 1 year

ParameterAny response Complete Response CR/PR (n=233)Others (No response/rescue) (n=60)OR (95% CI)P valueFemale/male, n (%)221(94.8)/12(5.2)48(80)/12(20)4.6(1.9-10.8)0.001Median age at nephritis onset28(11-65)25(13-67)0.079Median SLE duration12(0-232)18(0-144)0.770Hypertension, n (%)100(42.9)34(56.7)0.061Creatinine>1.3mg/dL (median, IQR)21(9.0)15(25)3.3(1.6-7.02)0.001eGFR categories, n (%)137(58.8)27(45)1.7(0.96-3.03)0.003>9057(24.5)15(25)61-9034(14.6)9(15)30-604(1.7)8(13.3)<30Active urinary sediments, n (%)132(56.7)44(73.3)0.019uPCR g/day (median with IQR)1.38(0.8-2.67)1.95(1.18-4.19)0.098Class III/IV, n (%)167(71.7)49(81.7)0.117Class V, n (%)17(7.3)5(8.3)0.788Combined class, n (%)7(3.0)3(5.0)0.469Activity score, median with IQR3(1-6)6(3-9)0.001Chronicity score, median with IQR0(0-1)1(0-2)5.06(1.49-17.21)0.001Presence of Crescents, no (%)43(18.5)17(28.3)0.104Fibrinoid necrosis, n (%)28(12.0)7(11.7)0.791Interstitial inflammation, n (%)86(36.9)33(55)2.08(1.17-3.70)0.003Interstitial fibrosis, n (%)23(10.7)9(15)0.273Tubular atrophy, n (%)64(27.5)27(45)0.003Blood vessel changes, n (%)2(0.9)1(1.7)0.606Fibrinoid necrosis206(88.4)50(83.3)0.339Other changes*Figure 1.

ROC curve and AUC for the three different models

Model 1: Baseline serum creatinine, urine PCR, male sex; AUC – 0.694(0.609-0.779), p <0.001

Model 2: Baseline serum creatinine, urine PCR, male sex, chronicity score; AUC – 0.740(0.660-0.820), p<0.001

Model 3: Baseline serum creatinine, urine PCR, male sex, chronicity score, crescents, interstitial inflammation; AUC – 0.744(0.664-0.824), p<0.001

Conclusion

Clinical and biochemical parameters can predict the renal histological class to a fair extent but has limited value in predicting the activity and chronicity parameters. Since a combination of clinical and histopathology parameters are better in predicting renal outcomes, performing renal biopsies should be encouraged in LN.

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

POS0392 ROLE OF SEMIQUANTITATIVE THIGH MAGNETIC RESONANCE IMAGING (tMRI) IN DETERMINING SKELETAL MUSCLE OUTCOMES AT BASELINE AND ON FOLLOW UP IN IDIOPATHIC INFLAMMATORY MYOPATHIES (IIMs)

Background

Idiopathic Inflammatory Myopathies (IIMs) are characterized by muscle inflammation and associated muscle weakness. Semiquantitative scoring of thigh Magnetic Resonance Imaging (tMRI) has shown contradictory results in associating muscle inflammation, damage, and clinically assessed muscle weakness. Moreover, there are no studies assessing the role of tMRI detected muscle damage in determining long-term recovery of muscle strength and endurance.

Objectives

To correlate tMRI scores for muscle edema, fascial edema, muscle atrophy, and fatty infiltration with consecutively collected manual muscle testing 8 (MMT-8) scores and muscle enzymes. To determine the role of baseline tMRI changes in achieving maximum muscle power during follow-up.

Methods

This is a retrospective analysis of a single-center myositis cohort. IIM patients (n=55) who underwent baseline tMRI (STIR and T1 sequences) at the time of diagnosis were included. Baseline demographic, clinical, and serological parameters were noted. MRI T1 weighted sequence and STIR sequence axial and coronal images were assessed for intramuscular and fascial edema, atrophy and fatty replacement using a semiquantitative score and the percentage of muscle involvement for each parameter was calculated. MMT-8 values and muscle enzyme levels which remained unchanged at least for 6 months during follow-up were noted for 42 patients. MMT-8 ≥74 was taken as near normal muscle power based on the fact that 75% of IIM patients in remission for a long duration achieved MMT-8 of≥74 in our cohort. Spearman correlation was done between clinical parameters, muscle enzymes, and tMRI scores. Baseline parameters of patients who achieved and did not achieve MMT8≥74 were compared. Multiple linear regression was performed to assess the tMRI variables predicting a higher MMT-8 during follow-up

Results

The median age was 36 (27.25-44.75) years, median duration of disease at presentation was 4 months (2-10), median duration of follow up was 24 months (6.75-38.25). Dermatomyositis, Polymyositis and Antisynthetase syndrome comprised of 58.2%, 7.3% and 30.9% cases respectively. Baseline muscle enzymes CPK(r=0.531), AST(r=0.535) and ALT(r=0.442) showed significant positive correlation(p<0.01) with muscle edema. Baseline MMT-8 showed significant negative correlation with muscle edema(r=-0.657) and fascial edema(r=-0.522) (p<0.01). Follow up MMT-8 showed significant negative correlation with muscle edema(r=-0.359), muscle atrophy (r=-0.319) and fatty infiltration(r=-0.308) (p<0.05) (Figure 1). Baseline MMT-8 and MRI fatty infiltration were significantly different between patients who achieved and did not achieve MMT-8 of ≥74 on follow-up (Table 1). Multiple regression analysis revealed adjusted R2 value of 0.386. Baseline MMT-8(β=0.372) and muscle atrophy(β=-0.459) significantly predicted MMT-8 on follow-up

Table 1.

Comparison between those who achieved near-normal muscle power versus others

Follow up MMT-8<74 (n=8)Follow up MMT-8 ≥74 (n=34)P-valueAge (years) (median, IQR)36.5(27-47.5)36(28.75-44.25)1.000Duration of disease (months) (median, IQR)6(4-10.5)3.5(2.75-9.75)0.459Baseline muscle enzymes and MMT-8 (median, IQR)CPK (IU/L)1758(116-6160)680(57.5-3595)0.410LDH (IU/L)496(240-823)616.50(289.25-753)0.672AST (IU/L)112(76-201.5)69.5(40.5-226.25)0.352ALT (IU/L)74.50(65.5-139.75)69(36-142.25)0.560MMT-8 baseline (0-80)49.5(47.25-56)63(53.75-73.25)0.007MRI thigh scores (median, IQR)Muscle edema%22.41(5.65-63.33)10.37(0.00-28.70)0.070Fascial edema %43.33(18.61-78.06)33.89(11.49-50.56)0.478Muscle atrophy %2.22(0.28-20.83)0.00(0.00-2.50)0.081Fatty infiltration %6.67(2.78-18.61)0.56(0.00-3.61)0.010Figure 1.

Correlation between baseline and Follow up MMT-8 with tMRI scores.

Conclusion

Low baseline MMT-8 and presence of muscle atrophy at baseline are predictors of poor outcome. Hence performing a baseline MRI will help in the prognosis.

Disclosure of Interests

None declared

AB1519 STEROID FREE REMISSION IN ORGAN THREATENING ANCA ASSOCIATED VASCULITIS: WITHOUT AVACOPAN

Background

Steroid free remission in organ threatening ANCA associated vasculitis is currently described only with Avacopan, a C5a receptor inhibitor. However, this drug is not yet available for use in the third world.(1)

Objectives

To describe a clinical case of granulomatous polyangiitis with orbital pseudotumor right eye with optic atrophy, who developed steroid induced central serous retinopathy in the other eye, necessitating a steroid free treatment regime.

Methods

A 45year old man was admitted to the department of clinical immunology, JIPMER in January 2021 with Orbital pseudotumor Rt eye since 2019 causing optic atrophy, treated with high dose steroids for more than a year. He developed steroid induced central serous retinopathy of left eye, necessitating withdrawal of steroids, leading to disease flare in the form of painful right orbital inflammation, acute glomerulonephritis, vasculitic ulcers over leg and lung nodules. His PR3 ANCA titers were elevated at the time of disease flare. His sputum infectious workup was negative for bacteria/fungus/tuberculosis. He was treated with 10 cycles of radiotherapy to right eye for debulking followed by exenteration. As he had pseudomonal infection in the post operative orbital cavity at the time of flare, 2 monthly doses of IVIG 2g/kg was given; infection treated with antibiotics and regular dressing. After resolution of infection 6 doses of cyclophosphamide as per EUVAS protocol and Rituximab 2 gm was given along with the first dose of Cyclophosphamide.

Results

At 48 weeks of follow up, he continues to be in sustained clinical remission without steroids. He has received additional 500 mg of rituximab at 28 weeks. His lung nodules and vasculitic ulcers of leg healed over 34 weeks. He has developed saddle nose deformity for which reconstruction is planned.

Conclusion

Steroid free remission in GPA may be possible without Avacopan.

References

[1]Jayne DRW, Merkel PA, Schall TJ, Bekker P. Avacopan for the Treatment of ANCA-Associated Vasculitis. N Engl J Med. 2021 Feb 18;384(7):599–609.

Table 1.

Investigations:

Week 0Week 28Week 48 Hemoglobin(g/dl)5.57.810.7 Creatine (mg/dl)1.431.351.0 Albumin (mg/dl)1.92.53.8 Urine analysisProtein:2+RBCs:50 -100/hpfProtein:1+RBCs: 10-15/hpfProtein: traceRBCs: <10/hpf CECT ThoraxLeft upper lobe solitary noduleResolved MRI orbitRT orbital pseudotumor with optic atrophyS/P exenteration Renal BiopsyFocal proliferative sclerosing glomerulonephritis; No crescents.Orbital tissue biopsyPalisading granulomaPR3 ANCA(ELISA)57.63MPO ANCA(ELISA)negativeANANegativeC3/C41.61/0.32 (normal)ACE levels25.3 (normal)IgG42.73BVAS2050VDI333

Abbreviations: hpf: high power field, CECT: Contrast enhanced computed tomography, PR3: proteinase3, MPO: Myeloperoxidase, ANA: Antinuclear antibodies, ACE: Angiotensin converting enzyme, BVAS: Birmingham vasculitis activity score, VDI: Vasculitis damage index

Figure 1.

Clinical features of GPA

Disclosure of Interests

None declared

Neuromyelitis optica spectrum disorder and systemic lupus erythematosus

Neuromyelitis optica spectrum disorder is an inflammatory syndrome that is associated with many autoimmune conditions. We present the case of a patient who had longitudinally extensive transverse myelitis and antibodies to aquaporin 4 IgG (AQP4-IgG). Based on presence of lymphopenia, further workup revealed strong ANA positivity, anti-Sm antibodies, and low serum complements suggesting presence of systemic lupus erythematosus. The patient promptly responded to intravenous pulse methylprednisolone and five sessions of plasma exchange. At 1 year, she is on maintenance treatment with low dose prednisolone, azathioprine, and hydroxychloroquine, she has had no relapse and no other clinical features of lupus. This case is an illustration that neuromyelitis optica spectrum disorder can be the first manifestation of systemic lupus erythematosus.

Neuromyelitis optica spectrum disorder and systemic lupus erythematosus

Neuromyelitis optica spectrum disorder is an inflammatory syndrome that is associated with many autoimmune conditions. We present the case of a patient who had longitudinally extensive transverse myelitis and antibodies to aquaporin 4 IgG (AQP4-IgG). Based on presence of lymphopenia, further workup revealed strong ANA positivity, anti-Sm antibodies, and low serum complements suggesting presence of systemic lupus erythematosus. The patient promptly responded to intravenous pulse methylprednisolone and five sessions of plasma exchange. At 1 year, she is on maintenance treatment with low dose prednisolone, azathioprine, and hydroxychloroquine, she has had no relapse and no other clinical features of lupus. This case is an illustration that neuromyelitis optica spectrum disorder can be the first manifestation of systemic lupus erythematosus.

Acute hypopituitarism complicating Russell's viper envenomation: case series and systematic review

BACKGROUND

Chronic hypopituitarism following Russell viper envenomation (RVE) is a rare but well-recognized syndrome. The clinical features, associations, management and outcomes of RVE associated-acute hypopituitarism (AHP) are not well described.

AIMS

To describe the clinical features, intensive care unit (ICU) management and outcomes of a series of patients with RVE-AHP and identify the clinical associations of RVE-AHP.

METHODS

We describe a series of patients with prospectively identified AHP related to RVE and describe our findings comparing RVE with and without AHP and a systematic search of literature on AHP related to RVE.

RESULTS

We identified nine cases of AHP related to RVE. Unexplained hypoglycemia (100%) and hypotension (66.7%) were the most common findings at presentation. AHP occurred after a median of 9 (range, 2-14) days after severe envenomation and was associated with multi-organ dysfunction, lower platelet counts, more bleeding and transfusions when compared to patients with RVE alone. The presence of clinically defined capillary leak syndrome, disseminated intravascular coagulation and mortality were not different from those without AHP. Our systematic search yielded 12 cases of AHP related to RVE; data on associated clinical manifestations, therapy and ASV administration were not available in most reports.

CONCLUSION

AHP is a very rare complication of RVE. Unexplained hypoglycemia and hypotension should prompt evaluation for AHP in RVE. AHP is associated with severe RVE, multi-organ dysfunction, bleeding and need for transfusion. Prompt treatment with steroids may reduce mortality related to AHP in RVE.

Clinical significance of antiphospholipid antibodies in Indian scleroderma patients

In patients with systemic sclerosis (SSc), antiphospholipid antibodies (aPL) have been reported to be associated with more severe manifestations including digital infarct, gangrene and pulmonary hypertension. But these findings are not consistent in all studies; moreover, there are no data available from Indian subcontinent. The objective of this study is to assess the prevalence of antiphospholipid antibodies in Indian SSc patients and correlate them with clinical and immunological features. Seventy-two patients were recruited prospectively from rheumatology clinic from 2002 to 2006. Their medical records were reviewed. Anticardiolipin antibodies (IgG, IgM) by ELISA and lupus anticoagulant (LA) were tested in standardized pattern and repeated after 6 weeks. Anti-β2 glycoprotein-I antibodies were done in patients who had aPL antibodies. Nineteen patients had diffuse cutaneous SSc and 53 had limited disease. Seven patients (9.7%) were positive for aPL antibodies in their sera. Only one patient had clinical features of antiphospholipid antibody syndrome and manifested with recurrent abortions and deep vein thrombosis. She was positive for aCL, LA and anti-β2 glycoprotein-I antibodies. Four patients were only aCL (IgG) positive in moderate titers and one each had only aCL (IgM) and LAC positivity. None of the clinical parameters showed an association with aPL antibody.

Anti-cyclic citrullinated peptide antibodies in juvenile idiopathic arthritis

OBJECTIVE

Prevalence and clinical significance of anti-cyclic citrullinated peptide (CCP) antibodies in Indian patients with juvenile idiopathic arthritis (JIA).

METHODS

Anti-CCP antibodies were determined by enzyme-linked immunosorbent assay (ELISA) in 78 patients with JIA which included all 3 major subtypes of the disease: pauciarticular, polyarticular afld systemic onset. Values above 5 relative units were taken as positive. Associations between anti-CCP antibodies and clinical and laboratory and radiological parameters were determined.

RESULTS

Anti-CCP antibodies were positive in only 2 of 34 (5.9%) patients with pauciarticular JIA and 3 of 17 (17.6%) of systemic,.pnset JIA, whereas it was positive in 13 of 27 (48.1%) of polyarticular JIA patients (p < 0.001). Furthermore, it was seen that among patients with polyarticular JIA, RF-lgM positive patients had higher rate of anti-CCP antibody positivity with 7 of 8 (87.5%) patients having positive anti-CCP antibody (p<0.001). Similarly, patients with erosions (11/19; p<0.001) and deformities (5/-10; p<0.001) were found to have significant association with anti-CCP antibody positivity.

CONCLUSION

Anti-CCP antibodies could be detected more frequently in the sera of JIA patients with severe manifestations like-erosions and deformity. It was also more significantly associated with seropositive polyarticular JIA than other types. It can be presumed from these results that anti-CCP antibodies can be used as a marker to predict severe course of JIA at the onset to guide optimal aggressive therapy.

Unusual lung mass: benign or malignant?

Primary adenoid cystic carcinoma of lung is a rare tumour. It is a slowly growing, indolent tumour. Average time that elapses before diagnosis is reported to be two years. We report the case of a patient who remained well inspite of harbouring primary adenoid cystic carcinoma of lung for 15 years.