Epidemiological and clinical evolution of multisystem inflammatory syndrome in children throughout the SARS-CoV-2 pandemic in a tertiary Italian children's hospital

Multisystem inflammatory syndrome in children (MIS-C) is a potentially life-threatening disease temporally linked to SARS-CoV-2 whose incidence and clinical presentation may have been altered by the different SARS-CoV-2 variants and by vaccination.

METHODS

We retrospectively collected the data of all MIS-C cases admitted to the Gaslini Children's Hospital, the hub for SARS-CoV-2 related diseases in Liguria region, Italy, from 01 October 2020, to 30 November 2022, evaluating the ratio between MIS-C cases and (1) COVID-19 paediatric cases in our region, (2) emergency department admissions and (3) emergency department febrile patients. We also compared MIS-C incidence in pre- post-vaccination periods.

RESULTS

We observed a significant global decline in the incidence of MIS-Cover the four variant periods and after the starting of vaccination whereas clinical features, therapeutic management and severity did not significantly vary.

CONCLUSIONS

In our setting, we demonstrated a significant decrease of MIS-C incidence according to the predominant variant and including not vaccinated children. Regardless of variant type, the patients showed similar phenotypes and severity throughout the pandemic. SARS-CoV-2 variants as well as immune protection after previous infections and/or vaccination may have interacted by playing different roles and reducing the incidence of MIS-C.

Pyrin Inflammasome Activation Defines Colchicine-Responsive SURF Patients from FMF and Other Recurrent Fevers

Syndrome of undifferentiated recurrent fever (SURF) is characterized by recurrent fevers, a lack of confirmed molecular diagnosis, and a complete or partial response to colchicine. Despite the clinical similarities to familial Mediterranean fever (FMF), the underlying inflammatory mechanisms of SURF are not yet understood. We here analyzed the in vitro activation of the pyrin inflammasome in a cohort of SURF patients compared to FMF and PFAPA patients. Peripheral blood mononuclear cells (PBMC) were collected from SURF (both colchicine-treated and untreated), FMF, PFAPA patients, and healthy donors. PBMC were stimulated ex vivo with Clostridium difficile toxin A (TcdA) and a PKC inhibitor (UCN-01), in the presence or absence of colchicine. The assembly of the pyrin inflammasome was evaluated by measuring the presence of apoptosis-associated Speck-like protein containing caspase recruitment domain (ASC) specks in monocytes using flow cytometry. IL-1β secretion was quantified using an ELISA assay. No differences in TcdA-induced activation of pyrin inflammasome were observed among FMF, PFAPA, and healthy donors. Untreated SURF patients showed a reduced response to TcdA, which was normalized after colchicine treatment. In contrast to FMF, SURF patients, similar to PFAPA patients and healthy donors, did not exhibit pyrin inflammasome activation in response to UCN-01-mediated pyrin dephosphorylation. These data demonstrate that in vitro functional analysis of pyrin inflammasome activation can differentiate SURF from FMF and PFAPA patients, suggesting the involvement of the pyrin inflammasome in the pathophysiology of SURF.

TNFRSF1A-pR92Q variant identifies a subset of patients more similar to systemic undifferentiated recurrent fever than TNF receptor-associated periodic syndrome

OBJECTIVES

To describe the clinical phenotype and response to treatment of autoinflammatory disease (AID) patients with the TNFRSF1A-pR92Q variant compared to patients with tumour necrosis factor receptor-associated periodic syndrome (TRAPS) due to pathogenic mutations in the same gene and patients diagnosed with other recurrent fever syndromes including periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA) and syndrome of undefined recurrent fever (SURF).

METHODS

Clinical data from pR92Q variant associated AID, classical TRAPS, PFAPA and SURF patients were obtained from the Eurofever registry, an international, multicentre registry enabling retrospective collection of data on AID patients.

RESULTS

In this study, 361 patients were enrolled, including 77 pR92Q variant, 72 classical TRAPS, 152 PFAPA and 60 SURF patients. pR92Q carriers had an older age of disease onset than classical TRAPS and PFAPA patients. Compared to pR92Q variant patients, classical TRAPS patients had more relatives affected and were more likely to have migratory rash and AA-amyloidosis. Despite several differences in disease characteristics and symptoms between pR92Q variant and PFAPA patients, part of the pR92Q variant patients experienced PFAPA-like symptoms. pR92Q variant and SURF patients showed a comparable clinical phenotype. No major differences were observed in response to treatment between the four patient groups. Steroids were most often prescribed and effective in the majority of patients.

CONCLUSIONS

Patients with AID carrying the TNFRSF1A-pR92Q variant behave more like SURF patients and differ from patients diagnosed with classical TRAPS and PFAPA in clinical phenotype. Hence, they should no longer be diagnosed as having TRAPS and management should differ accordingly.

An Update on Familial Mediterranean Fever

(1) Background: Familial Mediterranean Fever (FMF) is the prototypal autoinflammatory disease, characterized by recurrent bursts of neutrophilic inflammation. (2) Methods: In this study we look at the most recent literature on this condition and integrate it with novel information on treatment resistance and compliance. (3) Results: The canonical clinical presentation of FMF is in children with self-limited episodes of fever and polyserositis, associated with severe long-term complications, such as renal amyloidosis. It has been described anecdotally since ancient times, however only recently it has been characterized more accurately. We propose an updated overview on the main aspects of pathophysiology, genetics, diagnosis and treatment of this intriguing disease. (4) Conclusions: Overall, this review presents the all the main aspects, including real life outcome of the latest recommendation on treatment resistance of FMF, a disease, that not only helped understanding the pathophysiology of the auto inflammatory process but also the functioning of the innate immune system itself.

Spontaneous NLRP3 inflammasome-driven IL1-β secretion is induced in severe COVID-19 patients and responds to anakinra treatment

BACKGROUND

SARS-CoV-2 infection may result in a severe pneumonia associated to elevation of blood inflammatory parameters, reminiscent of cytokine storm syndrome. Steroidal anti-inflammatory therapies have shown efficacy in reducing mortality in critically ill patients, however the mechanisms by which SARS-CoV2 virus triggers such an extensive inflammation remain unexplained.

OBJECTIVES

To dissect the mechanisms underlying SARS-CoV-2 associated inflammation in severe COVID-19 patients we studied the role of IL-1β, a pivotal cytokine driving inflammatory phenotypes, whose maturation and secretion are regulated by inflammasomes.

METHODS

We analyzed NLRP3 pathway activation by means of confocal microscopy, plasma cytokine measurement, cytokine secretion following in vitro stimulation of blood circulating monocytes and whole blood RNA sequencing. The role of ORF3a SARS-CoV2 protein was assessed by confocal microscopy analysis following nucleofection of a monocytic cell line.

RESULTS

We found that circulating monocytes from COVID-19 patients display ASC specks that colocalize with NLRP3 inflammasome and spontaneously secrete IL-1β in vitro. This spontaneous activation reverts following patient's treatment with the IL-1 receptor antagonist anakinra. Transfection of a monocytic cell line with cDNA coding for the ORF3a SARS-CoV2 protein, resulted in ASC speck formation CONCLUSIONS: These results provide further evidence that IL-1β targeting could represent an effective strategy in this disease and suggest a mechanistic explanation for the strong inflammatory manifestations associated to COVID-19.

Clinical characterization, long-term follow-up, and response to treatment of patients with syndrome of undifferentiated recurrent fever (SURF)

OBJECTIVES

To describe a homogeneous group of patients with undifferentiated recurrent fevers followed-up in a tertiary referral center for systemic autoinflammatory diseases (SAIDs).

METHODS

Patients with undifferentiated recurrent fevers seen at our Center from 2008 to 2021 and followed-up for at least one year were included in a retrospective study. Monogenic recurrent fevers, patients carrying variants of unknown origin and PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis) syndrome were excluded.

RESULTS

Fifty patients (34 male, 16 female) were included in the study. The median age at onset was 3 years, and the median follow-up was 3.3 years. At baseline, arthralgia (70%) and abdominal pain (65%) were the most frequent manifestations. NSAIDs or steroids on demand had a variable and transient effect. Tonsillectomy was ineffective in the 10 patients (20%) that underwent surgery. Forty-eight patients (96%) were treated with colchicine. A complete response (absence of fever) was achieved in 31 patients (64.6%). Nine patients (18%) showed a partial response, with a median reduction of fever episodes per year of 72%. Nine patients (16.7%) were considered resistant to colchicine. The presence of generalized lymphadenopathy and, to a lesser extent, exudative tonsillitis was associated with a lack of response to colchicine.

CONCLUSIONS

We describe the largest series of patients with syndrome of undifferentiated recurrent fever (SURF) reported in the literature so far. SURF should be considered as a distinct clinical entity in the context of multifactorial autoinflammatory diseases.

The impact of the Eurofever criteria and the new InFevers MEFV classification in real life: Results from a large international FMF cohort

INTRODUCTION

New Eurofever/PRINTO classification criteria (EPCC) for Familial Mediterranean Fever (FMF) and other recurrent fevers have been recently developed, together with the classification of the pathogenicity of MEFV variants.

OBJECTIVES

To evaluate the impact in real life of both the EPCC and INSAID pathogenicity classification of MEFV variants in the large international Eurofever FMF cohort.

METHODS

Baseline demographic, genetic and clinical data of FMF patients included in the Eurofever registry were evaluated. The EPCC and the 2018 INSAID classification for MEFV variants were applied in all eligible FMF patients.

RESULTS

Since November 2009, clinical information was available for 1012 FMF (532 males/480 females, 827 children/185 adults) from 119 centres. Complete data were available for 887 patients in whom 623 (70.2%) satisfied EPCC (EPCC+), while 264 (29.8%) did not (EPCC-). The majority of the EPCC- patients (172, 65.1%) displayed negative or non-informative genetics (monoallelic or biallelic benign variants, monoallelic variant of unknown significance). At baseline, colchicine was used in most of EPCC+ patients (88%) and in a lower percentage of EPCC- patients (69%, p < 0.0001), who were treated in a higher proportion with steroid or NSAID on demand (p = 0.003 and 0.008, respectively). Four percent of patients received Anti-IL-1 treatment.

CONCLUSIONS

The combination of EPCC and the 2018 INSAID classification of MEFV variants is able to identify two distinct groups of patients, which differ in clinical characteristics, therapeutic approach and response to treatment. EPCC+ patients displayed the typical features of FMF, while EPCC- patients had a more variable phenotype with a lower percentage of response to colchicine.

The challenge of early diagnosis of autoimmune lymphoproliferative syndrome in children with suspected autoinflammatory/autoimmune disorders

OBJECTIVES

To test the usefulness of an extended panel of lymphocyte subsets (LS) in combination with Oliveira's diagnostic criteria for the identification of autoimmune lymphoproliferative syndrome (ALPS) in children referred to a pediatric rheumatology center.

METHODS

patients referred from 2015 to 2018 to our Rheumatology Unit for an autoimmune or autoinflammatory condition were retrospectively analyzed. Oliveira's required criteria (chronic lymphoproliferation and elevated DNT) were applied as first screening. Flow cytometry study included double negative CD4-CD8-TCR αβ+T lymphocytes (DNT), CD25+CD3+, HLA-DR+CD3+T cells, B220+T cells, and CD27+B cells. Data were analyzed with an univariate logistic regression analysis, followed by a multivariate analysis. Sensitivity and specificity of the Oliveira's required criteria were calculated.

RESULTS

264 patients were included in the study and classified as: i) autoimmune diseases (26); ii) juvenile idiopathic arthritis (JIA) (35) iii) monogenic systemic autoinflammatory disease (SAID) (27); iv) PFAPA syndrome (100); v) systemic undefined recurrent fever (SURF) (45); vi) undetermined-SAID (14); vii) ALPS (17). Oliveira's required criteria displayed a sensitivity of 100% and specificity of 79%. When compared with other diseases the TCRαβ+B220+ lymphocytes were significantly increased in ALPS patients. The multivariate analysis revealed 5 clinical/laboratory parameters positively associated to ALPS: splenomegaly, female gender, arthralgia, elevated DNT and TCRαβ+B220+lymphocytes.

CONCLUSIONS

Oliveira's required criteria are useful for the early suspicion of ALPS. TCRαβ+B220+ lymphocytes should be added in the diagnostic work-up of patients referred to pediatric rheumatology unit for a suspected autoimmune or autoinflammatory condition, providing a relevant support in the early diagnosis of ALPS.

Efficacy of early anti-inflammatory treatment with high doses of intravenous anakinra with or without glucocorticoids in patients with severe COVID-19 pneumonia

BACKGROUND

IL-1 plays a pivotal role in the inflammatory response during cytokine storm syndromes.

OBJECTIVE

Our aim was to analyze the efficacy and safety of early anti-inflammatory treatment (AIT) with intravenous anakinra with or without glucocorticoids in coronavirus disease 2019 (COVID-19) pneumonia.

METHODS

We performed a retrospective single-center cohort study of patients admitted for COVID-19 pneumonia from February 26 to April 29, 2020, to assess the efficacy of early AIT with intravenous anakinra (100 mg every 8 hours for 3 days, with tapering) alone or in combination with a glucocorticoid (intravenous methylprednisolone, 1-2 mg/kg daily, with tapering). The standard of care (SOC) treatment was hydroxychloroquine and/or azithromycin with or without antivirals and anticoagulants. Late rescue AIT with anakinra or tocilizumab was also evaluated. Treatment effect on overall survival was assessed by a propensity score-adjusted Cox model.

RESULTS

A total of 128 patients were analyzed; 63 patients received early AIT (30 received anakinra alone and 33 received anakinra plus a glucocorticoid) at admission, and 65 patients did not receive early AIT and were used as controls; of the latter 65 patients, 44 received the SOC treatment alone and 21 received the SOC treatment plus late rescue AIT. After adjustment for all the unbalanced baseline covariates, early AIT reduced the hazard of mortality by 74% (adjusted hazard ratio [HR] = 0.26; P < .001). The effect was similar in patients receiving anakinra alone (adjusted HR = 0.28; P = .04) and anakinra plus a glucocorticoid (adjusted HR = 0.33; P = .07). Late rescue treatment did not show a significant advantage over SOC treatment alone (adjusted HR = 0.82; P = .70).

CONCLUSIONS

This study suggests, on a larger series of patients with COVID-19 pneumonia, the potential efficacy and safety of the early use of high doses of intravenous anakinra with or without glucocorticoids.

OP0273 ADHERENCE TO COLCHICINE TREATMENT AND COLCHICINE RESISTANCE IN A MULTICENTRIC FMF NATIONAL COHORT

Background:

Colchicine is the standard treatment for Familiar Mediterranean Fever (FMF), however about 5% of patients experience colchicine resistance. There is no standard definition of colchicine resistance. Recently a panel of experts elaborated a new definition based on a Delphi consensus approach.

Objectives:

We aim to describe main features of the disease and clinical outcome of a cohort of FMF patients with particular interest on the colchicine resistance and tolerability according to the definitions proposed by the recent consensus.

Methods:

Since November 2009, 425 Italian pediatric and adult FMF patients (pts) from 13 centers were enrolled in a national longitudinal cohort study, using the international EUROFEVER registry. Demographic, genetic and clinical data, including response to treatment, were analyzed. Supplementary information on health related quality of life and treatment adherence was also collected by a specific questionnaire.

Results:

Complete information were available in 341 pts (189 M and 152 F, 211 children and 120 adults). The median age at disease onset was 5.0 years (1 m-59 y); the mean diagnostic delay was 8.7 y (range 0-61 y). The median age at enrollment was 12.1 y (range 3 m - 82 y). The MEFV genotype was the following: 103 (30.2%) pts carried biallelic pathogenic variants; 59 (17.3%) one pathogenic variants and one VOUS /LB variant; 27 (7.9%) had biallelic VOUS/LB variants; 97 (28.45%) were heterozygous for pathogenic variants; 30 (8.8%) were heterozygous for VOUS/LB, 25 (7.33%) were genetically negative.

Colchicine treatment was used in 280 pts; during treatment, biologic treatment (anti-IL1) in 22 pts. 61 pts received NSAID or steroid on demand.

We analyzed the behavior of the pts treated with colchicine according to the statements on colchicine resistance/intolerance defined by Ozen et al (1) (Table 1).

Table 1.Adherence62% displayed a total adherence (> 90% of prescription); 10.8% a good adherence (50-89% of prescriptions); 1.9% poor adherence (< 50% of prescriptions); 0.9% no adherenceDose adjustment criteria/ Recommended maximum colchicine doseMean colchicine dose:Pts <5 years: 0.57mg/de (std. dev. 0.18)5-10 year: 0.77mg/die (std. dev. 0.23)10-18 years: 1.1mg/die (std. dev. 0.39)Adults: 1.16 mg/die (std. dev. 0.37)Pts with a dose inferior to the minimum recommended dose5-10 years: 2.5%10-18 years: 15%Adults: 4%Resistance to ColchicineResistance was be defined as persistence of fever attacks, despite optimal treatment. 41.6% pts had a complete disease control32.8% Pts had < 1 episode/month for 3 months25.5% had ≥1 episode/month for 3 monthsInclusion of secondary amyloidosis in the definition of colchicine resistance5 adult pts (1.5%) displayed amyloidosisColchicine intolerance11 pts (3.2%) withdraw colchicine because of drug intolerancePatient quality of life and patient-reported outcomes20.7% of pts experience fatigue or chronic pain, 16.9% limitations in daily activities, and 16.9% have lost school/work days.

Conclusion:

Almost 58% of FMF pts display disease activity despite colchicine treatment. The treatment is generally under-dosed, especially in children. The adherence and the compliance to the treatment is generally good.

References:

[1]Ozen S et all. Recommendation on colchicine dosing and definition of colchicine resistance/intolerance in the management of FMF. Pediatric Rheumatology, 2019.

Acknowledgments:

This research was financial supported by Novartis AG

Disclosure of Interests:

Romina Gallizzi: None declared, Marta Bustaffa: None declared, Francesca Mazza: None declared, Diana Sutera: None declared, Giovanna Fabio: None declared, Laura Obici: None declared, Maria Alessio: None declared, Donato Rigante: None declared, Luca Cantarini: None declared, Antonella Insalaco: None declared, Marco Cattalini: None declared, Maria Cristina Maggio: None declared, Gabriele Simonini: None declared, Alma Nunzia Olivieri: None declared, Serena Pastore: None declared, Maddalena Lancieri: None declared, Nicolino Ruperto Grant/research support from: Bristol-Myers Squibb, Eli Lily, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi (paid to institution), Consultant of: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Speakers bureau: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Marco Gattorno Consultant of: Sobi, Novartis, Speakers bureau: Sobi, Novartis

THU0501 EARLY DIAGNOSIS OF THE AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME (ALPS) IN PATIENTS WITH UNDEFINED AUTOINFLAMMATORY OR AUTOIMMUNE DISORDERS: THE PRACTICAL ROLE OF A FLOW CYTOMETRY PANEL

Background:

ALPS is a rare disorder due to a defective apoptotic mechanism leading to abnormal lymphoproliferation and autoimmunity. The disease is difficult to identify in the early phase when it may be misdiagnosed. Elevated TCR alpha-beta CD4-CD8- lymphocytes (double negative T lymphocytes DNT) together with hyperIgG, high levels of IL10, Il18, vitamin B12 and soluble Fas ligand have been suggested as the main ALPS hallmarks (1). Therefore, a specific flow cytometry panel (DNT cells, ratio of CD25+CD3+ to HLA−DR+CD3+ cells, increased B220+ T-cells, and decreased CD27+ memory B cells) has been proposed to serve as a diagnostic screen for ALPS (2).

Objectives:

To evaluate the usefulness of a specific lymphocyte flow cytometry panel in the early identification of ALPS/ALPS-like disorders in a cohort of patients with undefined autoinflammatory or autoimmune disorders.

Methods:

The clinical data of patients referred to the pediatric Rheumatology Unit of the Istituto Giannina Gaslini Hospital for a suspicion of autoimmune or autoinflammatory condition from October 2015 to April 2018, were retrospectively analyzed. Data on clinical manifestations, laboratory workup, genetic analysis and treatment were collected. Flow cytometry was included among the screening panel: DNT, CD25+CD3+, HLA−DR+CD3+ cells, B220+ T-cells, and CD27+ memory B cells were included. A statistical analysis was performed: data were analyzed with an univariate logistic regression analysis, to identify the most significant variables associated with ALPS. These variables were then included in a multivariate analysis to select a set of clinical and laboratory parameters, each of them associated with a significant probability to be associated with ALPS independently from other variables.

Results:

475 patients were retrospectively analized. 211 patients not fulfilling the inclusion criteria were excluded. The patients were classified as follows: i) Autoimmune disease 26 pts (10 SLE; 3 MCTD; 6 jDM; 5 Behçet; 1 SjS; 1 Kawasaki) ii) Juvenile Idiopathic Arthritis 35 pts iii) Monogenic systemic autoinflammatory disease (MSAID) 27 pts (17 FMF; 3 MKD; 1 TRAPS; 4 DADA2; 2 SAVI) iv) PFAPA 100 pts v) Systemic Undefined Recurrent Fever 45 pts vi) Undetermined-SAID 15 pts vii) ALPS/ ALPS probable 16 pts. The flow cytometry panel showed, as expected, an elevation of DNT in all ALPS patients. Among the other parameters, CD3CD25+/CD3HLADR+, and B220+ T cells, were significatively altered in 75% of ALPS patients. Conversely, B CD27+ did not differentiate ALPS from the other subgroups. The multivariate analysis revealed 5 clinical/laboratory parameters that showed the higher independent association to ALPS in the cohort of patients. Splenomegaly, female gender, elevated DNT, arthralgia and elevated alfabeta+B220+ lymphocytes were positively and significantly associated to ALPS.

Conclusion:

The use of the specific flow cytometry panel, comprehensive of DNT, B220+, HLA-DR and CD25, in patients with undefined autoinflammatory or autoimmune disorders may identify a subgroup of patients with ALPS.

References:

[1]Joao B. Oliveira et al. Blood 2010; 116 (14): e35–e40.

[2]Lenardo MJ et al.Immunity. 2010;32(3):291–295.

Disclosure of Interests:

Caterina Matucci Cerinic: None declared, Leonardo Oliveira Mendonca: None declared, maurizio miano: None declared, paola terrnaova: None declared, federica casabona: None declared, Marta Bustaffa: None declared, Francesca Bovis: None declared, Roberta Caorsi: None declared, Stefano Volpi: None declared, Angelo Ravelli: None declared, Carlo Dufour: None declared, Marco Gattorno Consultant of: Sobi, Novartis, Speakers bureau: Sobi, Novartis