Diagnostic difficulties in polymyalgia rheumatica cases with normal erythrocyte sedimentation rate and C-reactive protein values

Polymyalgia Rheumatica (PMR) is an inflammatory disease which does not have specific diagnostic tests or pathological symptoms and is identified based on clinical characteristics. Among acute phase reactants (APR), the erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) are laboratory findings used in diagnosis and follow-up. In this study, it was aimed to determine the incidence of normal ESH and CRP in patients diagnosed with PMR and identify the distinguishing characteristics of these patients. PMR patients who were clinically diagnosed at a single center were reviewed. After the presence of bursitis was demonstrated with ultrasonography in patients with normal ESR and CRP rates, they were accepted to have PMR. Among all 54 patients (63% female), ESR and CRP values were normal in 8 patients (14%), and serum amyloid A (SAA) was determined to be elevated in all these patients. In the comparisons of the groups with normal and high levels of ESR and CRP, it was found that the group with normal ESR and CRP values had a younger age of diagnosis (P = .027), a longer symptom duration (P < .001), and a lower comorbidity rate (P = .010). PMR patients can have normal ESR and CRP values at the time of their diagnosis. While bursitis can be demonstrated with ultrasonography in patients who are clinically evaluated to have PMR, APRs such as SAA other than ESR and CRP can also be used.

The diagnostic dilemma in a patient with neuroleptic malignant syndrome during the COVID-19 pandemic: A significant increase in acute phase reactants

Key Clinical Message

In some patients, neuroleptic malignant syndrome is accompanied significant high levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP).

Abstract

Neuroleptic malignant syndrome (NMS) is an idiosyncratic life-threatening adverse reaction and usually triggered in response to antipsychotic drugs. In addition, leukocytosis and increased muscle enzymes levels (especially creatine phosphokinase) are observed in NMS. In addition, a transient increase in different types of acute phase reactants in NMS has been mentioned. This article describes a woman treated with haloperidol, perphenazine, escitalopram, and alprazolam because she developed catatonic symptoms after psychological stress. She suffered from NMS symptoms and had elevated CRP and ESR levels, among other signs and symptoms. Given the COVID-19 pandemic and reports of co-occurrence of catatonia and NMS and COVID-19 and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), this patient was a diagnostic dilemma. After consultation with the consultation-liaison psychiatry units, she was managed adequately with electroconvulsive therapy and lorazepam.

Investigation of biomarkers in a rare case of fulminant necrotizing enterocolitis in a preterm infant

We encountered a very rare case of fulminant necrotizing enterocolitis (F-NEC) in a preterm male baby. The course of NEC and sepsis in this case was clearly different from the usual course. After onset at 14 days of life, catheter-related bloodstream infection was first assumed, and antibiotics and γ-globulin administration were started. However, 12 hours after onset, the baby's abdominal distension increased remarkably, and his entire abdominal wall turned red to purple. Escherichia coli were isolated from the blood culture, but the catheter tip culture was negative. Exchange transfusion was performed 32 hours after onset, but no significant changes were observed in the baby's general condition, and he died 46 hours after onset. The acute phase reactants of CRP and α1-acid glycoprotein increased, but haptoglobin did not. Although IL-1β and TNFα increased as expected with sepsis, IL-6, IL-8, IL-10, and G-CSF however increased to a greater extent than expected. From the above, we diagnosed the development of intestinal necrosis as a result of widespread intestinal ischemia, and that sepsis was associated with this poor condition.

Examination of cord blood at birth in women with SARS-CoV-2 exposure and/or vaccination during pregnancy and relationship to fetal complete blood count, cortisol, ferritin, vitamin D, and CRP

Background

SARS-CoV-2 is known to manifest a robust innate immune response. However, little is known about inflammatory influences from maternal SARS-CoV-2 infection or maternal mRNA vaccination upon the fetus. In addition, it is unknown if Vitamin D deficiency influences fetal homeostasis or if an anti-inflammatory mechanism to the development of possible innate cytokines or acute phase reactants by the maternal/fetal dyad, in the form of cortisol elevations, occur. In addition, effects on Complete Blood Count (CBC) are not known.

Objective

To evaluate the neonatal acute phase reactants and anti-inflammatory responses after maternal SARS-CoV-2 disease or mRNA vaccination.

Methods

Samples and medical records reviews from mother/baby dyads (n = 97) were collected consecutively, and were categorized into 4 groups; no SARS-CoV-2 or vaccination exposure (Control), Vaccinated mothers, maternal SARS-CoV-2 disease positive/IgG titer positive fetal blood, and maternal SARS-CoV-2 positive/IgG titer negative fetal blood. SARS-CoV-2 IgG/IgM/IgA titers, CBC, CRP, ferritin, cortisol, and Vitamin D were obtained to examine the possible development of an innate immune response and possible anti-inflammatory response. Student's t-test, Wilcoxon rank-sum, and Chi-squared with Bonferroni corrections were used to compare groups. Multiple imputations were performed for missing data.

Results

Cortisol was higher in babies of both mothers who were vaccinated (p = 0.001) and SARS-CoV-2 positive/IgG positive (p = 0.009) as compared to the control group suggesting an attempt to maintain homeostasis in these groups. Measurements of ferritin, CRP, and vitamin D did not reach statistical significance. CBC showed no variation, except for the mean platelet volume (MPV), which was elevated in babies whose mothers were vaccinated (p = 0.003) and SARS-CoV-2 positive/IgG positive (p = 0.007) as compared to the control group.

Conclusion

Acute phase reactant elevations were not noted in our neonates. Vitamin D levels were unchanged from homeostatic levels. Cord blood at birth, showed Cortisol and MPV higher in vaccinated and SARS-CoV-2 IgG positive mother/baby dyads as compared to the Control group, indicating that possible anti-inflammatory response was generated. The implication of possible inflammatory events and subsequent cortisol and/or MPV elevation effects upon the fetus after SARS-CoV-2 disease or vaccination is unknown and merits further investigation.

Acute Phase Reactants: Relevance in Dermatology

Acute phase reactants (APRs) are a heterogeneous group of plasma proteins whose concentration either increases or decreases by at least 25% during an inflammatory process. The conditions that commonly lead to acute phase response are infection, trauma, burns, tissue infarction, inflammatory conditions, and advanced malignancy. APRs are elevated in all infective conditions. In skin and soft tissue infection, the levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) help to predict the severity of infection. Procalcitonin can be used to differentiate between viral and bacterial infections. During active stages of systemic lupus erythematosus (SLE), ESR is elevated, but CRP either remains normal or shows only moderate elevation. In the case of superadded bacterial infection in SLE, CRP is elevated. In SLE, ferritin levels are elevated during the active stage of the disease. Serum amyloid antigen (SAA) and CRP levels are significantly higher in patients with early and late stages of diffuse systemic sclerosis. Elevated levels of serum ferritin are seen in rheumatoid arthritis and adult-onset Still's disease. CRP, SAA, and α2-macroglobulin (α ₂M) are elevated in active psoriasis. In severe psoriasis, the ferritin-iron ratio is elevated. In drug-induced maculopapular rash, drug-induced hyperaemic vasculitis, and severe drug-induced cutaneous adverse reactions, CRP levels are elevated during the active stages. Neoplastic diseases in general are accompanied by increased serum ferritin. Further detailed studies are required to explore the clinical significance of APRs in dermatology and the scope of their possible application as a diagnostic tool.

From bench to bedside: Calprotectin (S100A8/S100A9) as a biomarker in rheumatoid arthritis

S100A9/S100A8 (calprotectin), a member of the S100 protein family, has been shown to play a pivotal role in innate immunity activation. Calprotectin plays a critical role in the pathogenesis of rheumatoid arthritis (RA), as it triggers chemotaxis, phagocyte migration and modulation of neutrophils and macrophages. Higher calprotectin levels have been found in synovial fluid, plasma, and serum from RA patients. Recent studies have demonstrated better correlations between serum or plasma calprotectin and composite inflammatory disease activity indexes than c-reactive protein (CRP) or the erythrocyte sedimentation rate (ESR). Calprotectin serum levels decreased after treatment, independently of the DMARD type or strategy. Calprotectin has shown the strongest correlations with other sensitive techniques to detect inflammation, such as ultrasound. Calprotectin independently predicts radiographic progression. However, its value as a biomarker of treatment response and flare after tapering is unclear. This update reviews the current understanding of calprotectin in RA and discusses possible applications as a biomarker in clinical practice.

Ferritin, Serum Iron and Hemoglobin as Acute Phase Reactants in Laparoscopic and Open Surgery of Cholecystectomy: An Observational Prospective Study

Cytokines are expressed by various cells after several stimuli such as surgical tissue damage, producing a systemic inflammatory response (SIR). C-reactive protein (CRP) is used extensively in clinical practice after operative injury, but proinflammatory cytokines, iron status, albumin, neutrophil-to-lymphocyte (N/L) ratio and hemoglobin, as acute phase reactants, have been poorly documented. This study aims to show how they behave after surgery, comparing laparoscopic (LC) versus open cholecystectomy (OC). In total, 55 patients were included in a prospective non-randomized form to undergo a cholecystectomy: 8 patients OC (50% females) and 47 patients LC (68% females). Before (A1) and 24 h after surgery (A2), blood samples were taken for an ordinary analysis and IL6, IL8 and TNFα determination. There were no differences between LC and OC groups concerning age, CRP, IL6 and TNFα at day A1. In the LC group at day A2, CRP, IL6, IL8, TNF, ferritin, leukocytes and N/L ratio increased; hemoglobin, lymphocytes, prothrombin and albumin decreased (p < 0.05). In the OC group at day A2, only IL6 (p < 0,07), ferritin, leukocytes, N/L ratio and CRP (p < 0.05) increased; serum iron, hemoglobin, lymphocytes and albumin (p < 0.05) decreased. At day A2, OC vs. LC group, higher values were observed in IL6, ferritin and CRP (p ≤ 0.05), and lesser values were observed in serum iron and prothrombin (p < 0.05). In conclusion, classic markers of inflammation are altered after surgery, in a milder way in laparoscopic surgery. Ferritin can be used as an inflammatory marker, as has been described in COVID-19 infection.

Disease activity correlates and functionality in patients with rheumatoid arthritis - real-world experience from a South Asian country

Introduction

There is a lack of data assessing disease activity in patients with rheumatoid arthritis from Pakistan. We sought to determine the correlation between Disease Activity Score 28 (DAS28) and disease activity parameters and the modified Health Assessment Questionnaire (mHAQ). Secondarily, we evaluated the concordance of acute phase reactants with disease activity.

Material and methods

We prospectively studied 132 patients with rheumatoid arthritis (RA) as per the 2010 American College of Rheumatology/European League Against Rheumatism criteria, not in clinical remission. Based on the DAS28 score, the patients were divided into low, moderate, and high activity groups. The patients were also categorized according to the elevation of acute phase reactants to determine concordance and discordance with DAS28-ESR and DAS28-CRP. Descriptive statistics and Pearson's correlation were computed.

Results

Complete demographics was available for 132 participants. The mean age was 46.2 ±12.8 years; there were 85.6% (n = 113) females. The mean disease duration was 5.7 ±6.4 years. The (Rephrase as mean ±SD) DAS28 and mHAQ scores were 3.4 ±1.8 and 0.77 ±0.68, respectively. A significant correlation was observed between DAS28 and tender and swollen joint count (r = 0.64; p < 0.001); DAS28 and mHAQ (r = 0.47; p-value < 0.001), DAS28 and patient's global assessment (PGA) (r = 0.45; p-value < 0.001). A weak correlation was observed between mHAQ and CRP and ESR, with r = 0.242 and 0.225, respectively, p-value < 0.001. In comparison, no correlation of DAS28 with the rheumatoid factor (r = -0.035) or ACPA antibody (r = -0.094) was noted. A positive concordance between ESR and CRP was observed in severely active RA.

Conclusions

From an outpatient setting in a South Asian country, DAS28-ESR emerged as the preferred choice for an accurate assessment of disease severity in RA when combined with the mHAQ. Acute phase reactants increase positively in concordance with severely active RA, although discordant in low to moderately active disease.

Exposing and Overcoming Limitations of Clinical Laboratory Tests in COVID-19 by Adding Immunological Parameters; A Retrospective Cohort Analysis and Pilot Study

Background

Two years since the onset of the COVID-19 pandemic no predictive algorithm has been generally adopted for clinical management and in most algorithms the contribution of laboratory variables is limited.

Objectives

To measure the predictive performance of currently used clinical laboratory tests alone or combined with clinical variables and explore the predictive power of immunological tests adequate for clinical laboratories. Methods: Data from 2,600 COVID-19 patients of the first wave of the pandemic in the Barcelona area (exploratory cohort of 1,579, validation cohorts of 598 and 423 patients) including clinical parameters and laboratory tests were retrospectively collected. 28-day survival and maximal severity were the main outcomes considered in the multiparametric classical and machine learning statistical analysis. A pilot study was conducted in two subgroups (n=74 and n=41) measuring 17 cytokines and 27 lymphocyte phenotypes respectively.

Findings

1) Despite a strong association of clinical and laboratory variables with the outcomes in classical pairwise analysis, the contribution of laboratory tests to the combined prediction power was limited by redundancy. Laboratory variables reflected only two types of processes: inflammation and organ damage but none reflected the immune response, one major determinant of prognosis. 2) Eight of the thirty variables: age, comorbidity index, oxygen saturation to fraction of inspired oxygen ratio, neutrophil-lymphocyte ratio, C-reactive protein, aspartate aminotransferase/alanine aminotransferase ratio, fibrinogen, and glomerular filtration rate captured most of the combined statistical predictive power. 3) The interpretation of clinical and laboratory variables was moderately improved by grouping them in two categories i.e., inflammation related biomarkers and organ damage related biomarkers; Age and organ damage-related biomarker tests were the best predictors of survival, and inflammatory-related ones were the best predictors of severity. 4) The pilot study identified immunological tests (CXCL10, IL-6, IL-1RA and CCL2), that performed better than most currently used laboratory tests.

Conclusions

Laboratory tests for clinical management of COVID 19 patients are valuable but limited predictors due to redundancy; this limitation could be overcome by adding immunological tests with independent predictive power. Understanding the limitations of tests in use would improve their interpretation and simplify clinical management but a systematic search for better immunological biomarkers is urgent and feasible.

Do Redox Balance and Inflammatory Events Take Place in Mild Bronchiectasis? A Hint to Clinical Implications

We hypothesized that in mild bronchiectasis patients, increased systemic inflammation and redox imbalance may take place and correlate with clinical parameters. In plasma samples from patients with very mild bronchiectasis, inflammatory cells and molecules and redox balance parameters were analyzed. In the patients, lung function and exercise capacity, nutritional status, bacterial colonization, and radiological extension were assessed. Correlations between biological and clinical variables were determined. Compared to healthy controls, levels of acute phase reactants, neutrophils, IgG, IgA, myeloperoxidase, protein oxidation, and GSH increased and lung function and exercise capacity were mildly reduced. GSH levels were even greater in ex-smoker and Pseudomona-colonized patients. Furthermore, radiological extension inversely correlated with airway obstruction and, disease severity, and positively correlated with neutrophil numbers in mild bronchiectasis patients with no nutritional abnormalities. In stable patients with mild bronchiectasis, several important inflammatory and oxidative stress events take place in plasma. These findings suggest that the extension of bronchiectasis probably plays a role in the development of redox imbalance and systemic inflammation in patients with mild bronchiectasis. These results have therapeutic implications in the management of bronchiectasis patients.

The Recruitment-Secretory Block ("R-SB") Phenomenon and Endoplasmic Reticulum Storage Diseases

In this article, we review the biological and clinical implication of the Recruitment-Secretory Block (“R-SB”) phenomenon. The phenomenon refers to the reaction of the liver with regard to protein secretion in conditions of clinical stimulation. Our basic knowledge of the process is due to the experimental work in animal models. Under basal conditions, the protein synthesis is mainly carried out by periportal (zone 1) hepatocytes that are considered the “professional” synthesizing protein cells. Under stimulation, midlobular and centrolobular (zones 2 and 3) hepatocytes, are progressively recruited according to lobular gradients and contribute to the increase of synthesis and secretion. The block of secretion, operated by exogenous agents, causes intracellular retention of all secretory proteins. The Pi MZ phenotype of Alpha-1-antitrypsin deficiency (AATD) has turned out to be the key for in vivo studies of the reaction of the liver, as synthesis and block of secretion are concomitant. Indeed, the M fraction of AAT is stimulated for synthesis and regularly exported while the Z fraction is mostly retained within the cell. For that reason, the phenomenon has been designated “Recruitment-Secretory Block” (“R-SB”). The “R-SB” phenomenon explains why: (a) the MZ individuals can correct the serum deficiency; (b) the resulting immonohistochemical and electron microscopic (EM) patterns are very peculiar and specific for the diagnosis of the Z mutation in tissue sections in the absence of genotyping; (c) the term carrier is no longer applicable for the heterozygous condition as all Pi MZ individuals undergo storage and the storage predisposes to liver damage. The storage represents the true elementary lesion and consequently reflects the phenotype-genotype correlation; (d) the site and function of the extrahepatic AAT and the relationship between intra and extracellular AAT; (e) last but not least, the concept of Endoplasmic Reticulum Storage Disease (ERSD) and of a new disease, hereditary hypofibrinogenemia with hepatic storage (HHHS). In the light of the emerging phenomenon, described in vitro, namely that M and Z AAT can form heteropolymers within hepatocytes as well as in circulation, we have reviewed the whole clinical and experimental material collected during forty years, in order to evaluate to what extent the polymerization phenomenon occurs in vivo. The paper summarizes similarities and differences between AAT and Fibrinogen as well as between the related diseases, AATD and HHHS. Indeed, fibrinogen gamma chain mutations undergo an aggregation process within the RER of hepatocytes similar to AATD. In addition, this work has clarified the intriguing phenomenon underlying a new syndrome, hereditary hypofibrinogenemia and hypo-APO-B-lipoproteinemia with hepatic storage of fibrinogen and APO-B lipoproteins. It is hoped that these studies could contribute to future research and select strategies aimed to simultaneously correct the hepatocytic storage, thus preventing the liver damage and the plasma deficiency of the two proteins.

Association Between Severity Grading Score And Acute Phase Reactants In Patients With Crimean Congo Hemorrhagic Fever

As the COVID-19 pandemic continues, countries still have to struggle with their endemic diseases such as Crimean-Congo hemorrhagic fever (CCHF). Severity grading score (SGS) is a practical approach and may shed light on the course of the CCHF, whose pathogenesis is not clearly understood, and have no effective treatments. It is aimed to assess the association between SGS and acute phase reactants (APR). Laboratory-confirmed patients were categorized by severity scores, and the relationship between APR and SGS was evaluated. A significant correlation between SGS and C-reactive protein (CRP) was found (p < 0.001). High SGS was associated with mortality and high CRP levels were used to predict the mortality at the beginning of the hospital admission. To predict the outcome of the disease and for appropriate patient management, SGS and APR can be used simultaneously.

Marked Increased Production of Acute Phase Reactants by Skeletal Muscle during Cancer Cachexia

Simple Summary

Muscle wasting during cancer is recognized as an independent predictor of mortality. The aim of this study was to characterize the changes in the muscle secretome associated with cancer cachexia to gain a better understanding of the mechanisms involved and to identify secreted proteins which may reflect this wasting process. Our study demonstrated that skeletal muscle is a source of several acute phase reactants during cancer cachexia that may hold the key to a cachexia-specific signature. Future work will have to determine whether some of these acute phase reactants contribute to and/or reflect the muscle atrophy caused by cancer, therefore representing potential therapeutic targets and/or biomarkers of cancer cachexia.

Abstract

Loss of skeletal muscle mass in cancer cachexia is recognized as a predictor of mortality. This study aimed to characterize the changes in the muscle secretome associated with cancer cachexia to gain a better understanding of the mechanisms involved and to identify secreted proteins which may reflect this wasting process. The changes in the muscle proteome of the C26 model were investigated by label-free proteomic analysis followed by a bioinformatic analysis in order to identify potentially secreted proteins. Multiple reaction monitoring and Western blotting were used to verify the presence of candidate proteins in the circulation. Our results revealed a marked increased muscular production of several acute phase reactants (APR: Haptoglobin, Serine protease inhibitor A3N, Complement C3, Serum amyloid A-1 protein) which are released in the circulation during C26 cancer cachexia. This was confirmed in other models of cancer cachexia as well as in cancer patients. Glucocorticoids and proinflammatory cytokines are responsible for an increased production of APR by muscle cells. Finally, their muscular expressions are strongly positively correlated with body weight loss as well as the muscular induction of atrogens. Our study demonstrates therefore a marked increased production of APR by the muscle in cancer cachexia.

GlycA: A New Biomarker for Systemic Inflammation and Cardiovascular Disease (CVD) Risk Assessment

The GlycA test is a recently developed proton nuclear magnetic resonance (¹H-NMR) spectroscopy-based assay that has been gaining increased interest as a serum biomarker for systemic inflammation, and consequently, as a potential biomarker for cardiovascular disease (CVD) risk assessment. The test has undergone investigation in several large cohort studies, since its development, to assess its predictive value for incident CVD events, CVD-associated mortality, and all-cause mortality. Despite variation in the generated estimates by these studies, they have all consistently demonstrated moderate-strength positive correlations between baseline GlycA levels, and incident CVD event rates and associated mortality. These correlations withheld testing even after adjusting for several other established CVD risk factors, including notable inflammatory biomarkers such as high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6). Compared with hsCRP, which is a well-known inflammatory biomarker for CVD risk assessment, GlycA has a comparable predictive value for future CVD-related events. However, the indications to pursue GlycA testing, and its clinical utility in patient care management, are yet to be determined. In this review, we define the GlycA test and what it "measures", and provide a brief summary of the findings of studies showing its association with incident CVD rates, and CVD-related mortality, as well as its correlation with other inflammatory biomarkers, namely hsCRP. Finally, we highlight the analytical advantages of the GlycA test, compared with "traditional" inflammatory biomarkers, while also mentioning its current limitations.

Depression and Inflammation in Patients With Lung Cancer: A Comparative Analysis of Acute Phase Reactant Inflammatory Markers

BACKGROUND

Depression and inflammation are intertwined, which is particularly relevant for patients with lung cancer who have an abundance of inflammation and experience depression. Acute phase reactants (APRs), albumin and C-reactive protein (CRP), are easily interpretable indirect markers of inflammation that have never been concomitantly compared with depression. Inflammation increases CRP (positive APR) and decreases albumin (negative APR). We hypothesize that albumin will be similarly associated with depression, thereby helping to inform the diagnosis of inflammatory depression.

OBJECTIVE

Compares the relationship between depression and representative positive and negative acute phase reactants in patients with metastatic lung cancer.

METHODS

Patients (n = 109) with metastatic lung cancer were evaluated for depression using the Hospital Anxiety and Depression Scale. Inflammation as measured by positive (CRP) and negative (albumin) APRs along with demographic and treatment variables were analyzed for associations with depression.

RESULTS

Depression was associated with lower albumin (r = -0.35, P < 0.001), higher CRP (r = 0.47, P < 0.001), and the CRP/albumin ratio (r = 0.45, P < 0.001). Hierarchical linear regression modeling found that albumin was associated with depression when controlling for demographics, disease, and treatment types (β = -0.28, P = 0.01). When both APRs were in the model, only CRP predicted depression (β = 0.31, P = 0.01), and albumin did not moderate CRP and depression. CRP/albumin ratio did not add to understanding depression variability, but patients with both low albumin and high CRP had particularly severe depression.

CONCLUSION

Albumin is associated with depression but not to a greater extent than CRP. The coupling of lower albumin and higher CRP describes more severe depression. Positive and negative APRs may form a distinct biologic signature to help identify patients with inflammatory depression in the lung cancer setting.

Types of acute phase reactants and their importance in vaccination

Vaccines are considered to be one of the most cost-effective life-saving interventions in human history. The body's inflammatory response to vaccines has both desired effects (immune response), undesired effects [(acute phase reactions (APRs)] and trade-offs. Trade-offs are more potent immune responses which may be potentially difficult to separate from potent acute phase reactions. Thus, studying acute phase proteins (APPs) during vaccination may aid our understanding of APRs and homeostatic changes which can result from inflammatory responses. Depending on the severity of the response in humans, these reactions can be classified as major, moderate or minor. In this review, types of APPs and their importance in vaccination will be discussed.

[Analysis of the first 100 patients with COVID-19 admitted to internal medicine wards at the Hospital de Clínicas José de San Martin, Buenos Aires University]

This retrospective descriptive study analyzes the clinical and epidemiological characteristics, the disease evolution and its association with laboratory markers of poor prognosis of the first 100 patients with COVID-19 admitted to internal medicine wards at the Hospital de Clínicas José de San Martín, University of Buenos Aires. Thirty-one patients were nursing home residents, the most common clinical manifestations were fever, cough and odynophagia. Regarding comorbidities, obesity was the most frequent one and hypertension was the most prevalent in patients with pneumonia. The most important predictors of mortality were age and pneumonia. Patients older than 70 years had higher acute phase reactants showing an exaggerated inflammatory response. Mortality was high (13%), compared to most reports (5%), probably because of the advanced age of our population and the unfavorable clinical conditions they presented at admission.

Intrathecal, Not Systemic Inflammation Is Correlated With Multiple Sclerosis Severity, Especially in Progressive Multiple Sclerosis

Objective: To test the hypothesis that Multiple Sclerosis (MS) patients have increased peripheral inflammation compared to healthy donors and that this systemic activation of the immune system, reflected by acute phase reactants (APRs) measured in the blood, contributes to intrathecal inflammation, which in turn contributes to the development of disability in MS. Methods: Eight serum APRs measured in a prospectively-collected cross-sectional cohort with a total of 51 healthy donors and 291 untreated MS patients were standardized and assembled into related biomarker clusters to derive global measures of systemic inflammation. The resulting APR clusters were compared between diagnostic categories and correlated to equivalently-derived cerebrospinal fluid (CSF) biomarkers of innate and adaptive immunity. Finally, correlations were calculated between biomarkers of systemic and intrathecal inflammation and MS severity measures, which predict future rates of disability progression. Results: While two blood APR clusters were elevated in MS patients, only one exhibited a weak correlation with MS severity. All CSF inflammation clusters, except CSF albumin, correlated with at least one measure of MS severity, with biomarkers of humoral adaptive immunity exhibiting the strongest correlations, especially in Progressive MS. Conclusion: Systemic inflammation does not appear to be strongly associated with intrathecal inflammation in MS. Positive correlations between markers of intrathecal inflammation, especially of humoral immunity, with MS severity measures support a pathogenic role of intrathecal (compartmentalized) inflammation in central nervous system tissue destruction, including in Progressive MS.

Increases in Acute Phase Reactants in a Patient with Scurvy Despite No Inflammation: Review of Literature

So far, little attention has been paid to the increase in acute phase reactants (APRs) in patients with scurvy. We report that elevated levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and serum amyloid A were shown in a pediatric patient with scurvy despite the absence of inflammation. These peculiar findings are important to discriminate scurvy from other rheumatic diseases.

The relationship between CRP gene polymorphism (rs2794521, rs3091244), ASDAS-CRP and ASDAS-ESR in ankylosing spondylitis

Background: We aimed to investigate the haplotypes and alleles of two variants (rs2794521 and rs3091244) in AS patients and to examine their relationship with ASDAS-CRP and ASDAS-ESR values.Methods: We evaluated 160 AS patients diagnosed according to the ASAS criteria. ASDAS-CRP and ASDAS-ESR values were calculated. ESR and CRP were examined. The restriction fragment length polymorphism (RFLP) method was used for detecting the rs2794521 and rs3091244 regions on the CRP gene.Results: As a result of the evaluation of rs2794521 gene polymorphism using PCR, TT, TC and CC genotypes were observed in 90, 81 and 9 individuals, respectively. As a result of the evaluation of rs3091244 gene polymorphism, CC, AC and TT genotypes were observed in 104, 51 and 5 individuals, respectively. T allele and C allele were found in rs2794521 gene by 75% and 25%, respectively. In addition, T allele, C allele and A allele were found in rs3091244 gene by 80%, 17% and 3%, respectively. With the help of regression equation, ASDAS-CRP level was 0.34 units higher in cases with rs3091244 C allele than cases without rs3091244 C alleles.Conclusion: CRP rs3091244 C allele may be associated with the increased relative risk for ASDAS-CRP.

Menstrual cycle-associated effects on some acute phase reactants parameters of Students in Usmanu Danfodiyo University Sokoto, North Western Nigeria

BACKGROUND

The menstrual cycle is the cycle of natural variations that occurs in the uterus and ovary as an essential part of making sexual reproduction possible. It is characterized by hormonal changes but the changes that occur in some active phase reactants (APR) parameters have not been fully elucidated.

OBJECTIVE

The aim of this study was to compare the serum albumin, ESR, and C-reactive protein levels in follicular and luteal phases of menstruation.

METHODS

A total of 90 healthy regularly menstruating women where used for this study. Forty-five of the study participants were in their follicular phase while the other 45 where in their luteal phase. Four milliliters of blood were withdrawn from each patient under aseptic condition and two milliliters was dispensed into EDTA container while the other two milliliters were dispensed into a plane container. The EDTA anticoagulated blood was used for ESR and full blood count while the serum from the plain tubes was used for analysis of C-reactive protein and Serum Albumin. Sysmex K-3 auto-analyser (Sysmex, Kobe Japan) was used for te determination of full blood count, the Westergren method was used for ESR estimation, Bromo Cresyl Green method was used for serum albumin and ELISA method was used for CRP determination. Data analysis was carried out using SPSS version 23.

RESULTS

This study showed a statistically significant difference in the ESR (p= 0.03) among menstruating women in the follicular and luteal phases of menstruation. Sociodemographic factors had no statistically significant effect on the APR parameters of menstruating women in the follicular and luteal phases of menstruation (p> 0.05). There were no statistically significant differences between acute phase proteins of menstruating women in the follicular phase and luteal phases (p> 0.05). Also, age and marital status did not affect the acute phase proteins among menstruating women in the follicular phase and luteal phases (p> 0.05).

CONCLUSIONS

There is need to generate data on menstrual disorders and their impact on women's health status, quality of life and social integration. It is vital that evaluation and treatment of menstrual complaints should be given a higher priority in primary care programs. There is need to invest in public enlightenment program to increase awareness in secondary schools to increase the level of awareness among adolescents as well as young females.

Synergy between serum amyloid A and secretory phospholipase A2

Serum amyloid A (SAA) is an evolutionally conserved enigmatic biomarker of inflammation. In acute inflammation, SAA plasma levels increase ~1,000 fold, suggesting that this protein family has a vital beneficial role. SAA increases simultaneously with secretory phospholipase A₂ (sPLA₂), compelling us to determine how SAA influences sPLA₂ hydrolysis of lipoproteins. SAA solubilized phospholipid bilayers to form lipoproteins that provided substrates for sPLA₂. Moreover, SAA sequestered free fatty acids and lysophospholipids to form stable proteolysis-resistant complexes. Unlike albumin, SAA effectively removed free fatty acids under acidic conditions, which characterize inflammation sites. Therefore, SAA solubilized lipid bilayers to generate substrates for sPLA₂ and removed its bioactive products. Consequently, SAA and sPLA₂ can act synergistically to remove cellular membrane debris from injured sites, which is a prerequisite for tissue healing. We postulate that the removal of lipids and their degradation products constitutes a vital primordial role of SAA in innate immunity; this role remains to be tested in vivo.

Cell boundaries are made up of fatty substances known as lipids. When cells get severely damaged, their lipid membranes break apart. These broken fragments of membrane become highly toxic, and must be removed as soon as possible to allow the tissue to heal. A small protein called serum amyloid A, SAA for short, was recently proposed to play a pivotal role in this process. In humans, SAA levels in the blood rapidly spike to over a thousand times their normal level following inflammation, injury or infection. Combined with the fact SAA has been conserved for over 500 million years, this suggests that SAA must be important for survival. But, it is not entirely clear how this protein works.

One clue for how SAA works is its relationship to another ancient protein called secretory phospholipase A₂. This protein, also known as sPLA₂, is part of a big family of enzymes that break down lipids in the cell membrane. Notably, sPLA₂ levels rise at the same time and place as SAA during inflammation. This led Jayaraman et al. to ask whether SAA and sPLA₂ might be working together to clean up the cell membrane debris.

To find out, Jayaraman et al. mixed mouse SAA with vesicles of membrane lipids, and then added sPLA₂. This revealed that SAA reshapes the lipid membrane into smaller ‘nanoparticles’ with tightly curved surfaces that are easier for sPLA₂ to break down. As the sPLA₂ breaks up these particles, SAA then gathers up and gets rid of the leftover toxic fragments. This suggests that SAA has two roles: helping sPLA₂ break down the membrane, and removing any toxic debris.

Clearing debris after injury is essential for proper healing. So, understanding how it works is crucial to find new ways to treat inflammation. Further work to understand SAA and sPLA₂ could improve our understanding of how to treat acute and chronic inflammation and its life-threatening complications.

Hepatic serum amyloid A1 upregulates interleukin-17 (IL-17) in γδ T cells through Toll-like receptor 2 and is associated with psoriatic symptoms in transgenic mice

Serum amyloid A (SAA) is an acute phase protein with pro-inflammatory cytokine-like properties. Recent studies have revealed that SAA promoted interleukin-17 (IL-17) production by various cells, including γδ T cells. γδ T cells are innate immune cells and express Toll-like receptor 2 (TLR2) on their surface, which is one of the SAA receptors. In this study, we investigated the relationship between γδ T cells and SAA1 through TLR2, by using hepatic SAA1-overexpressing transgenic (TG) mice. By injecting CU-CPT22, which is a TLR2 inhibitor, into the mice, we confirmed that SAA1 induced IL-17 in γδ T cells through TLR2. In vitro studies have confirmed that SAA1 increased IL-17 secretion in γδ T cells in combination with IL-23. We also observed a thickened epidermis layer and granulocyte penetration into the skin similar to the pathology of psoriasis in TG mice. In addition, strongly expressed SAA1 and penetration of γδ T cells in the skin of TG mice were detected. The exacerbation of psoriasis is associated with an increase in IL-17 levels. Therefore, these symptoms were induced by IL-17-producing γδ T cells increased by SAA1. Our study confirmed that SAA1 was a prominent protein that increased IL-17 levels through TLR2 in γδ T cells, confirming the possibility that SAA1 may exacerbate inflammatory diseases through γδ T cells.

Common Evaluations of Disease Activity in Rheumatoid Arthritis Reach Discordant Classifications across Different Populations

Objectives

The classification of disease activity states in rheumatoid arthritis (RA) can be achieved through disease activity indices, such as the Disease Activity Score in 28 joints erythrocyte sedimentation rate (DAS28-ESR), the Simplified Disease Activity Index (SDAI), and the Clinical Disease Activity Index (CDAI). Subjective measurements, such as patient reported outcomes have been incorporated into several of these indices alongside more objective assessments, such as increases in the ESR and C-reactive protein. Moreover, while they use similar criteria, different indices weight these criteria to different extents. Therefore, the classifications based on each evaluation may not always be the same. We aim to compare the performance of the three indices and their individual components in two different populations.

Methods

Data from Dutch and Portuguese adherent centers were extracted from the METEOR database, a multinational collaboration on RA. We included a total of 24,605 visits from Dutch centers (from 5,870 patients) and 20,120 visits from Portuguese centers (from 3,185 patients). We compared the disease activity states as evaluated by the DAS28-ESR, CDAI, and SDAI across the two populations. In addition, we analyzed the individual components of each evaluation, including their respective contributions to the outcome, in each population.

Results

We found significant differences in the disease activity states classified with the DAS28-ESR between the two populations. SDAI and CDAI had more congruous results. While the proportion of visits to Dutch and Portuguese centers that were classified as “in remission” was very similar between the CDAI and SDAI, the DAS28-ESR gave discordant results. Dutch patients had lower ESRs, which is more heavily weighted in the DAS28-ESR. In addition, even though the mean physicians’ global assessment values did not vary significantly for Dutch vs Portuguese physicians, we found that doctors at Portuguese centers overall scored the physician’s global assessment lower than Dutch physicians for patient visits classified by disease activity state.

Conclusion

While the CDAI and SDAI assigned disease activity states that were largely similar, the DAS28-ESR was often discordant across the two populations. Moreover, we found that physicians, more than patients, evaluated disease activity differently among the Portuguese and Dutch populations.

Specific networks of plasma acute phase reactants are associated with the severity of chronic obstructive pulmonary disease: a case-control study

Objectives. A detailed understanding of the intricate relationships between different acute phase reactants (APRs) in chronic obstructive pulmonary disease (COPD) can shed new light on its clinical course. In this case-control study, we sought to identify the interaction networks of a number of plasma APRs in COPD, with a special focus on their association with disease severity. Methods. COPD cases and healthy smoking controls (3:1 ratio) were recruited in our outpatient pulmonary clinic. Cardiopulmonary exercise testing was used to rule out the presence of ischemic heart disease. All subjects were males as per protocol. Multiple plasma APRs - including α-2-macroglobulin, C-reactive protein (CRP), ferritin, fibrinogen, haptoglobin, procalcitonin (PCT), serum amyloid A (SAA), serum amyloid P, and tissue plasminogen activator (tPA) - were measured using commercial Acute Phase Bio-Plex Pro Assays and analyzed on the Bio-Plex manager software. Correlations between different APRs were investigated using a heat map. Network visualization and analyses were performed with the Cytoscape software platform. Results. A total of 96 COPD cases and 33 controls were included in the study. Plasma A2M, CRP, and SAP levels were higher in COPD patients than in controls. Circulating concentrations of haptoglobin and tPA were found to increase in parallel with the severity of the disease. Increasing disease severity was associated with distinct intricate networks of APRs, which were especially evident in advanced stages. Conclusions. We identified different networks of APRs in COPD, which were significantly associated with disease severity.

Bird's Eye View of a Neonatologist: Clinical Approach to Emergency Neonatal Infection

Though the incidence of neonatal infection in term and near-term infants is relatively low, incidence of infection in preterm very low birth weight infants is as high as 20-30% and may result in neurodevelopmental impairment or mortality. Pediatricians should be familiar with recognition and emergency management of life-threatening neonatal infections, such as congenital pneumonia, early onset sepsis, late onset sepsis, bacterial and fungal meningitis, disseminated neonatal herpes simplex virus (HSV), and HSV meningoencephalitis. For the pediatrician, it is logical to approach the management of these infections by time of onset, i.e., early versus late onset of infection. Perinatal risk factors and simple laboratory tests, such as total white blood-cell count, immature/total ratio, and C-reactive protein are helpful in guiding the decision of antibiotics therapy. Successful management of these critical infections depends upon early diagnosis and timely administration of adequate antibiotics. Empiric antibiotic therapy must cover the most likely pathogens according to the risk factors of each individual neonate, and therapy duration is dependent upon culture results, clinical course, and the microorganism. Future research may focus on developing a practical neonatal sepsis score system based on risk factors and common biomarkers, which are readily available at bedside to make early accurate decisions and achieve better outcomes.

High mobility group box 1 serum levels are increased in Behçet's disease, but not associated with disease activity or disease manifestations

OBJECTIVES

High mobility group box 1 (HMGB1) is a nuclear protein that acts as an alarmin when released into the extracellular milieu. HMGB1 is a biomarker of active disease in several systemic autoimmune diseases. Behçet's disease (BD) is a systemic inflammatory disorder with a waxing/waning course. The objective of this study is to evaluate serum HMGB1 levels as a possible biomarker for disease activity in BD.

METHODS

A cross-sectional study measuring serum HMGB1 levels was performed in 26 BD patients and 20 healthy controls. The Brazilian version of the simplified BD Current Activity Form (BR-BDCAFs) was used to measure disease activity.

RESULTS

Serum HMGB1 levels were higher in patients with active disease [3.82 (2.54-6.11) ng/ml], in patients with BD without active disease but still on therapy [2.76 (1.89-5.78) ng/ml] and in patients in remission without treatment [2.66 (1.86-4.70) ng/ml] than in healthy controls [0.96 (0.59-1.39) ng/ml], P < 0.001. Levels were comparable between BD patients with active disease, BD without active disease but still on therapy and those in remission without treatment (P = 0.432). There was no correlation between serum HMGB1 levels and BR-BDCAF(s) (ρ = 0.195; P = 0.339). No association could be found between serum HMGB1 levels and specific disease involvement or therapy. So serum HMGB1 levels cannot be used as a biomarker in BD.

CONCLUSION

Serum HMGB1 levels are increased in patients with BD as compared with healthy controls. However, no association was found with disease activity, specific organ involvement or therapy in BD.

Acute Phase Reactants in Infections: Evidence-Based Review and a Guide for Clinicians

There is increasing evidence to support the role of various acute phase reactants as an adjunct to clinical judgement in the management of various infections. Procalcitonin is more specific in diagnosing bacterial infections and has a wider role in the management of complex infections. Procalcitonin based antibiotic guidance is helpful in antibiotic management in patients with pneumonia and sepsis

Acute-phase reactants such as erythrocyte sedimentation rate and C-reactive protein have traditionally been used as markers for inflammation and as a measure of “sickness index” in infectious and noninfectious conditions. In the last decade, more data have become available on the wider and more specific role for these markers in the management of complex infections. This includes the potential role in early diagnosis, in differentiating infectious from noninfectious causes, as a prognostic marker, and in antibiotic guidance strategies. A better defined role for biological markers as a supplement to clinical assessment may lead to more judicious antibiotic prescriptions, and it has the potential for a long-term favorable impact on antimicrobial stewardship and antibiotic resistance. Procalcitonin as a biological marker has been of particular interest in this regard. This review examines the current published evidence and summarizes the role of various acute-phase markers in infections. A MEDLINE search of English-language articles on acute-phase reactants and infections published between 1986 and March 2015 was conducted. Additional articles were also identified through a search of references from the retrieved articles, published guidelines, systematic reviews, and meta-analyses.

Neutrophil-Lymphocyte Ratio Connected to Treatment Options and Inflammation Markers of Ankylosing Spondylitis

BACKGROUND

In recent years, white blood cells (WBCs) and their subtypes have been studied in relation to inflammation. The aim of our study was to assess the relationship between neutrophil-lymphocyte ratio (NLR) and ankylosing spondylitis (AS).

MATERIALS AND METHODS

We enrolled a total of 177 patients, 96 AS and 81 healthy controls. Complete blood count, WBC, neutrophil and lymphocyte levels were measured, and the NLR was calculated. In the assessment of AS, we used the erythrocyte sedimentation rate, C-reactive protein (CRP), the Bath Ankylosing Spondylitis Disease Activity Index, and the Bath Ankylosing Spondylitis Functional Index.

RESULTS

In the present study, 96 AS and 81 healthy individuals were enrolled. The mean age was 43.8 ± 12.9 and 46.5 ± 11.2 years, respectively. Mean disease duration of AS patients was 6.9 ± 5.6 years (median = 5, min-max = 1-25). The patients with AS had a higher NLR than the control individuals (mean NLR, 2.24 ± 1.23 and 1.73 ± 0.70, respectively, P < 0.001). A statistically significant positive correlation was observed between NLR and CRP (r = 0.322, P = 0.01). The patients receiving antitumor necrosis factor α therapy had a lower NLR than the patients receiving nonsteroidal anti-inflammatory drug therapy (mean NLR, 1.71 ± 0.62 and 2.41 ± 1.33, respectively, P = 0.02).

CONCLUSION

NLR may be seen as a useful marker for demonstrating inflammation together with acute phase reactants such as CRP and in evaluating the effectiveness of anti-TNF-α therapy.

A conformational change of C-reactive protein in burn wounds unmasks its proinflammatory properties

Tissue damage in burn injury leads to a rapid increase of leukocytes and acute phase reactants. Plasma levels of C-reactive protein (CRP) rise within hours after the insult. No deficiency of this protein has been reported in humans, suggesting it plays a pivotal role in innate immunity. CRP in circulation is composed of five identical subunits [pentameric CRP (pCRP)]. Recently, deposits of structurally modified CRP (mCRP) have been found in inflammatory diseases. Little is known about this structural change and how it affects CRP functions. We analyzed CRP deposits in burn wounds and serum by immunohistochemistry, western blot and dot blot analysis. CRP was deposited in necrotic and inflamed tissue, but not in adjacent healthy tissue. Tissue deposited CRP was detected by mCRP-specific antibodies and structurally different from serum pCRP. mCRP but not pCRP induced reactive oxygen species production by monocytes and facilitated uptake of necrotic Jurkat cells by macrophages. In addition, it accelerated migration of keratinocytes in a scratch wound assay. The structural changes that occur in pCRP upon localization to damaged and inflamed tissue in burn wounds result in a functionally altered protein with distinct functions. mCRP exhibits opsonic, proinflammatory and promigratory properties which modulate wound healing.

Serum amyloid a as a useful indicator of disease activity in patients with ankylosing spondylitis

PURPOSE

To investigate whether serum amyloid A (SAA) levels are increased in patients with ankylosing spondylitis (AS) and whether its levels correlate well with AS disease activity.

MATERIALS AND METHODS

Thirty-eight patients with AS and 38 age- and sex-matched control subjects were enrolled in this cross-sectional study. Their SAA levels were quantitatively measured by immunonephelometry. An established, self-administered instrument for evaluating disease activity (Bath Ankylosing Spondylitis Disease Activity Index, BASDAI) was used to measure and acute phase reactants, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), in patients with AS.

RESULTS

Patients with AS had a significantly higher mean SAA level than controls (9.52 +/- 7.49mg/L versus 2.73 +/- 1.57mg/L, p < 0.05), and the mean BASDAI score of patients with elevated SAA levels was significantly higher than that of patients with normal SAA levels (5.6 +/- 1.3 versus 4.4 +/- 1.5, p < 0.05). SAA levels showed significant correlations with BASDAI scores (r=0.431, p=0.007), ESR (r=0.521, p=0.001) and CRP levels (r=0.648, p < 0.001). Additionally, the correlation between ESR and CRP levels also appeared significant (r=0.703, p < 0.001). In those with normal ESR or CRP levels, SAA levels and BASDAI scores were elevated (p < 0.05) and showed a trend of positive correlation with one another.

CONCLUSION

Our data showed that SAA levels were increased in patients with AS and correlated well with disease activity. These findings suggest that SAA can be used as a valuable indicator of disease activity in AS.

Enhancement of lectin pathway haemolysis by immunoglobulins

We recently reported that indicator sheep erythrocytes (E) coated with mannan and sensitized with mannan-binding lectin (MBL) (E-M-MBL) are lysed by human serum in the absence of calcium via the lectin pathway of complement activation by a process which requires alternative pathway amplification and is associated with increased binding of and control by complement regulatory proteins C4 bp and factor H. In the present study, we investigated the effect of immunoglobulin (Ig) on this haemolysis. Co-sensitization of indicator E with anti-E haemolysin led to threefold enhancement of lectin pathway haemolysis in the absence of calcium, associated with increased binding of C3 and C5. Lysis was enhanced approximately twofold when E-M-MBL were chemically or immunologically coated with IgM or IgA, and fourfold when coated with IgG, prior to lysis in human serum-Mg-ethyleneglycol tetraacetic acid. The presence of haemolysin did not reduce the binding or inhibitory activity of C4 bp, and the enhancing activity of haemolysin was retained in serum depleted of C4 bp. By contrast, binding of factor H was greatly reduced in the presence of haemolysin, which had no enhancing effect in serum depleted of factor H. These experiments demonstrate the ability of IgG, IgM and IgA to enhance lectin pathway cytolysis, and that this enhancement occurs by neutralization of the inhibitory activity of factor H. Immunoglobulin enhancement of lectin pathway cytolysis represents another interaction between the innate and adaptive systems of immunity.