OP0096 THE DIFFERENCES BETWEEN SJÖGREN’S SYNDROME PATIENTS WITH COMBINED SERONEGATIVITY AND ANTI-RO/SSA SEROPOSITIVITY

Background:

Sjögren’s syndrome (SS) is characterized by B cell hyperactivity reflected by hypergammaglobulinemia as well as a plethora of autoantibodies including antinuclear antibodies (ANA), anti-Ro/SSA, anti-La/SSB and rheumatoid factors (RF). Previous studies have focused on the phenotype of single positive (ANA or anti-Ro/SSA or anti-La/SSB) or double positive (anti-Ro/SSA and anti-La/SSB positive) SS patients, showing differences regarding the age of diagnosis, sicca manifestations and specific extraglandular manifestations. To our knowledge, no study has ever explored the clinical spectrum of triple seronegative (anti-Ro/SSA + anti-La/SSB + RF negative) and quadruple seronegative (ANA +anti-Ro/SSA + anti-La/SSB + RF negative) SS patients.

Objectives:

To study the differences in the clinical phenotype of triple and quadruple seronegative (SS) patients in a large cohort of well characterized patients, after comparison with anti-Ro/SSA positive patients.

Methods:

From a total cohort of 1723 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 4 clinical centers ([Universities of Pisa and Athens, Harokopio and Ioannina, (PAHI)], those who have been found triple or quadruple seronegative were identified and compared with matched anti-Ro/SSA positive SS patients according to age of SS onset, disease duration and gender, in 1:1 and 1:2 ratio respectively. Glandular (dry mouth, dry eyes, parotid gland enlargement) and extra-glandular manifestations (Raynaud’s phenomenon, chronic fatigue arthralgias/myalgias, arthritis, palpable purpura, liver involvement, kidney involvement, lung involvement, neurologic involvement, long standing lymphadenopathy and lymphoma) were compared between the 2 seronegative groups and the anti-Ro/SSA positive control group. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Two hundred and four SS patients (11,8%) were identified as triple negatives and 53 (3,0%) as quadruple, with a median disease duration of 6 years (range: 0-41) and 5 years (range: 0-32) respectively. The matched anti-Ro/SSA controls were 204 for the triple and 103 for the quadruple negatives. Triple negatives had lower frequency of monoclonal gammopathy (5,5% vs 12,1% p=0,04), low C4 serum levels (23% vs 36%, p=0,009) and lymphoma (3,4% vs 9,8%, OR= 3,06, 95% CI =1,27-7,85) while quadruple negatives exhibited higher prevalence of dry eyes (100% vs 90%) and lower prevalence of long standing lymphadenopathy (2,7% vs 19,5%, p=0,001) and lymphoma (0% vs 15%, p=0,001) compared to anti-Ro/SSA matched controls.

Conclusion:

Combined seronegativity account for more than 10% of SS population and is associated with lower prevalence of lymphoma compared to anti-Ro/SSA positive patients.

Disclosure of Interests:

Loukas Chatzis: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Dimitris Fotiadis: None declared, Fotini Skopouli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Chiara Baldini: None declared, Haralampos M. Moutsopoulos: None declared, Athanasios Tzioufas: None declared, Andreas Goules: None declared

FRI0149 THE CLINICAL FEATURES OF SJÖGREN’S SYNDROME PATIENTS WITH EARLY AND LATE DISEASE ONSET

Background:

Sjögren’s syndrome (SS) affects mainly individuals of the 4thor 5thdecade of life, although patients with early (≤35 years old) or late (≥65 years old) disease onset have been described in the literature. The clinical spectrum of the disease extends from mild dryness to severe systemic vasculitis and lymphoproliferative disorders. The phenotypic diversity of SS is defined by many factors, including age, since many parameters related to age may affect the clinical expression of the disease. Few studies have been conducted to study the effect of age on the clinical phenotype of SS, though with limited number of patients. Large and well-defined groups of SS are required to address such questions.

Objectives:

To study the clinical phenotype of SS patients with early and late disease onset and to explore the association of age with lymphoma development in a unified multicenter cohort.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those with either early (≤35 years) or late (≥65 years) disease onset were identified and matched according to gender and disease duration with middle aged controls whose disease onset was at the 4thor 5thdecade of life. Glandular manifestations, extra-glandular manifestations, serologic characteristics and histologic features were compared between the 2 age groups and the middle-aged control groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Three hundred seventy-nine (19%) SS patients with early and 293 (15%) with late disease onset were identified and compared with 353 and 285 middle aged SS controls respectively. The median disease duration of patients with early onset was 12 years (range:0-68) and for those with late disease onset was 5 years (range: 0-27). SS patients with early disease onset had statistically significant higher frequency of Raynaud’s phenomenon, lymphadenopathy, hypergammaglobulinemia, anti-Ro/SSA, anti-La/SSB, rheumatoid factor, salivary gland enlargement, low C4 complement levels, leukopenia and lymphoma (10,3% vs 5,7%, p= 0.03, OR= 1,91, 95% CI: 1,11-3,27) while SS patients with late disease onset had more frequently dry mouth, interstitial lung disease and lymphoma (6,8% vs 2,1%, p=0,01, OR= 3,4. 95%CI: 1,35-1,81).

Conclusion:

In a multicenter cohort of 1997 consecutive SS patients, those with early and late disease onset comprise more than one third of the total SS population. Patients with early disease onset, exhibit robust B cell responses with traditional risk factors for lymphoma as opposed to patients with late disease onset. Both age groups have increased lymphoma prevalence but presumably for different reasons, since late onset patients lack classical predictors of lymphoma. Therefore, these predictors deserve further study in different disease subsets.

Disclosure of Interests:

Andreas Goules: None declared, Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Marco Binutti: None declared, Sara Zandonella Callegher: None declared, Loukas Chatzis: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Athanasios Tzioufas: None declared

THU0294 THE DIFFERENCES IN THE CLINICAL SPECTRUM OF CRYOGLOBULINEMIC VASCULITIS BETWEEN SJÖGREN’S SYNDROME AND HCV HEPATITIS

Background:

Cryoglobulinemic vasculitis (CV) is a serious complication of Sjögren’s syndrome (SS) and is closely associated with type II IgMk cryoglobulins. CV has been well documented in HCV patients without SS, and shares common features with CV in SS. So far, few studies have described the clinical picture of CV in HCV negative SS, but the number of studied patients was rather small and CV was not well defined. To better describe the clinical spectrum of CV in SS and explore the differences compared to HCV-related CV, a large cohort of well characterized patients is required.

Objectives:

To study the clinical phenotype of CV in HCV-negative SS patients, in a large cohort of well characterized patients, after applying stringent classification CV criteria and in comparison with the classical CV of HCV patients.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those who fulfil the 2011 classification criteria for CV were identified and compared with matched HCV-CV patients according to age and gender. Glandular, extra-glandular manifestations and serologic features were compared between the 2 CV groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Among the 1083 SS patients who have been evaluated for cryoglobulins, 114 (9,8%) were found positive. Seventy-one (6,5%) SS patients met the 2011 CV criteria while 44 patients presented with type II IgMk cryoglobulinemia without CV. Sixty nine of 71 (97%) SS related CV patients were females and 2 of 71 (3%) males. Forty eight of 71 (68%) had SS disease onset >35 and <65 years old while 14/71 (19,7%) and 9/71 (12,7%) had SS disease onset <35 and >65 years old respectively. The most common clinical manifestations of CV among SS patients were purpura (90%) followed by arthralgias (70%), fatigue (59%), Raynaud’s phenomenon (48%), lymphadenopathy (31%), peripheral neuropathy (22,3%), vasculitic ulcer (11,3%) and glomerulonephritis (11,3%). Interestingly, almost 50% of SS related CV patients developed lymphoma and displayed high frequency of strong predictors including purpura, low C4 complement (88,6%) and salivary gland enlargement (SGE). Compared to HCV-CV patients, SS-CV patients had higher frequency of sicca manifestations, SGE, fatigue, arthritis, Raynaud’s phenomenon, lymphadenopathy, type II IgMk cryoglobulins and lymphoma.

Conclusion:

The prevalence of cryoglobulinemia and CV among SS patients is about 10% and 6-7% respectively. SS-CV patients are mainly middle-aged females with purpura as the main clinical manifestation, and up to one half of them may develop lymphoma, which is rarer in HCV-CV. Compared to HCV-CV patients, SS patients with CV have more frequently sicca symptoms, SGE and type II IgMk cryoglobulins.

Disclosure of Interests:

Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Luca Quartuccio: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Loukas Chatzis: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Massimo Galli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Andreas Goules: None declared, Athanasios Tzioufas: None declared

FRI0161 PHENOTYPIC DIFFERENCES BETWEEN SJÖGREN’S SYNDROME PATIENTS WITH LOW AND HIGH-GRADE INFLAMMATION BASED ON SALIVARY GLAND FOCUS SCORE

Background:

Sjögren’s syndrome (SS) is characterized by the presence of lymphocytic infiltration around the ductal epithelium of the salivary and lachrymal glands. The periepithelial inflammatory lesions and the enclosed B cell component are responsible for the glandular and extraglandular manifestations of the disease. Previous studies have shown that the severity of inflammation observed within the salivary glands is correlated with the occurrence of extraglandular manifestations. However, in these studies either the number of patients is small or the SS criteria are not well defined. To explore the association between the degree of inflammation within the salivary glands and the phenotype of the disease, large and well characterized cohorts of SS patients is required.

Objectives:

To compare the phenotypic features of SS patients with low and high degree of inflammation within the minor salivary glands as reflected by the focus score (FS).

Methods:

From a total cohort of 1723 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 4 clinical centers ([Universities ofPisa,Athens,Harokopio andIoannina, (PAHI)], those who had performed a lip biopsy and the focused score was available, were classified into low grade (FS<3) or high grade (FS≥3). Glandular (dry mouth, dry eyes, parotid gland enlargement) and extra-glandular manifestations (Raynaud’s phenomenon, arthralgias/myalgias, arthritis, palpable purpura, liver involvement, kidney involvement, lung involvement, neurologic involvement, long standing lymphadenopathy and lymphoma) as well as serologic features (ANA, RF, anti-Ro/SSA, anti-La/SSB) were compared between the 2 groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Eight hundred and eight minor salivary gland biopsies were available and evaluated based on focus score at the initial evaluation of SS patients, of whom 753 had low grade (FS<3) and 153 high grade (≥3) inflammation. The median disease duration after SS diagnosis was not statistically significant different for the 2 groups (median: 4 years, range: 0-36 years). SS patients with high grade inflammation displayed higher prevalence of salivary gland enlargement (SGE) (40% vs 25%, p=0,0002), long standing lymphadenopathy (22% vs 14%, p=0,02), ANA (97% vs 88%, p=0,0001), anti-La/SSB (52% vs 32%, p<0,0001), RF (61,5% vs 48%, p=0,003), peripheral neuropathy (PN) (5,3% vs 1,5, p=0,01) and of lymphoma (26% vs 8%, p<0,0001, OR=4,142, 95%CI=2,65 to 6,47) compared to those with low grade inflammation.

Conclusion:

SS patients with FS ≥3 at the initial evaluation, display higher prevalence of lymphoma as well as higher B cell hyperactivity and certain clinical manifestations (SGE, PNS, lymphadenopathy) that constitute risk factors for lymphoma development.

Disclosure of Interests:

Loukas Chatzis: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Dimitris Fotiadis: None declared, Fotini Skopouli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Gorgoulis Vassilis: None declared, Chiara Baldini: None declared, Haralampos M. Moutsopoulos: None declared, Andreas Goules: None declared, Athanasios Tzioufas: None declared

Opposed independent effects and epistasis in the complex association of IRF5 to SLE

Genetic variation in the interferon regulatory factor 5 (IRF5) gene affects systemic lupus erythematosus (SLE) susceptibility. However, association is complex and incompletely defined. We obtained fourteen European sample collections with a total of 1383 SLE patients and 1614 controls to better define the role of the different IRF5 variants. Eleven polymorphisms were studied, including nine tag single nucleotide polymorphisms (SNPs) and two extra functional polymorphisms. Two tag SNPs showed independent and opposed associations: susceptibility (rs10488631, P<10(-17)) and protection (rs729302, P<10(-6)). Haplotype analyses showed that the susceptibility haplotype, identified by the minor allele of rs10488631, can be due to epistasis between three IRF5 functional polymorphisms. These polymorphisms determine increased mRNA expression, a splice variant with a different exon 1 and a longer proline-rich region in exon 6. This result is striking as none of the three polymorphisms had an independent effect on their own. Protection was independent of these polymorphisms and seemed to reside in the 5' side of the gene. In conclusion, our results help to understand the role of the IRF5 locus in SLE susceptibility by clearly separating protection from susceptibility as caused by independent polymorphisms. In addition, we have found evidence for epistasis between known functional polymorphisms for the susceptibility effect.

Bias in association studies of systemic lupus erythematosus susceptibility due to geographical variation in the frequency of a programmed cell death 1 polymorphism across Europe

We obtained eight collections of DNA samples from ethnically matched systemic lupus erythematosus (SLE) patients and controls from five European countries totaling 783 patients and 1210 controls. A highly significant cline in the frequency of the PD1.3 A allele was found among controls but not among SLE patients. The frequency of the PD1.3 A allele increased from the Northeast to the Southwest of Europe. The cline was clearly apparent (P=1.2 x 10(-6)) when data from controls of other five SLE susceptibility studies were included in the analysis. This variation has severely biased SLE association studies owing to the lack of parallel changes in SLE patients. As a consequence, the PD1.3 A allele was more common in SLE patients than in controls in the Northeast and Center of Europe, similar to controls in Southeast Europe, and less frequent than in the controls in the Southwest of the Continent. This dissociation in allele frequencies between SLE patients and controls in different subpopulations indicated that programmed cell death 1 variation and disease susceptibility are not independent but the type of relationship is currently unclear. As allele frequency clines are common in other polymorphisms their impact in genetic epidemiology studies should be carefully considered.