POS1254 RISK FACTORS FOR SEVERE COVID-19 INFECTION AMONG PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES (AIRD) AND THE IMPACT OF VACCINATIONS - AN ISRAELI, MULTI-CENTER EXPERIENCE

Background

AIRD patients (pts) may be more susceptible to severe COVID19.

Objectives

To determine the risk factors for severe COVID19 and the effect of vaccinations among AIRD pts followed at dedicated rheumatology clinics.

Methods

At the onset of the pandemic, we established a national registry of AIRD pts, diagnosed with COVID19, based on voluntary reporting by the treating rheumatologist. 12 centers from Israel participated in the study. COVID19 was confirmed by a positive SARS CoV2 PCR. The indications for PCR testing were clinical symptoms or close contact with an infected person. Severe illness was defined by SpO2 <94% in room air, respiratory rate of >30 breaths/min, PaO2/FiO2 <300 mm Hg, or lung infiltrates >50% on imaging. The registry included demographic data, AIRD diagnosis and duration, visceral involvement, co-morbidities, immunomodulatory treatment, date of diagnosis and severity of COVID19 disease, management, complications, duration of hospitalization, the dates of the mRNA vaccinations, lab results and outcome. We analyzed data from 1.3.2020 to 30.11.2021

Results

During the study period we experienced 4 outbreaks of COVID19 infection. Initially social distancing, followed by a lockdown were imposed. The low number of cases led to relaxation of the measures. Two more severe outbreaks followed, which triggered 2 new lockdowns. The 3rd outbreak ended almost 2 months after vaccination started (BNT162b2 mRNA COVID19 vaccine). From March 1st 2020 to April 30, 2021, 298 AIRD pts (70.8% females, mean (SD) age 53.3(15.3)) with confirmed COVID19 infection were included. 43.3%(129) had visceral involvement due to the AIRD. 58.7%(175 pts) were on conventional synthetic disease modifying drugs (csDMARDs), 44.6% (133) on biologic/targeted DMARDs and 40% (120) on prednisone. Almost 2/3 of pts had at least one comorbidity.

In a multivariate logistic regression analysis age, AIRD with pulmonary involvement, diabetes and treatment with prednisone, mycophenolate mofetil or JAK inhibitors were associated with hospitalization. Older age, renal and vascular involvement due to the AIRD, and congestive heart failure were associated with higher mortality.

The 4th outbreak occurred 6 months after the introduction of vaccines, with spreading of the delta variant: 110 AIRD pts with COVID19 were recorded. Demographic data, clinical AIRD‘s characteristics, immunomodulatory treatment and comorbidities were similar to the previous outbreaks. However, during the 4th outbreak, the proportion of pts with severe COVID19, the hospitalization and mortality rate were significantly lower as compared to the first 3 outbreaks (15% vs 24%, 27% vs 53%, 6.7% vs 9.1%, respectively). Among COVID19 pts, 25% received a 3rd vaccine dose (booster), 56% contracted infection more than 5 months after the 2nd vaccine dose and 24% were unvaccinated. Most of the pts who received the booster contracted the disease within a week of vaccination. The odds ratio for hospitalization in vaccinated pts compared to unvaccinated was 0.11 (0.01 – 0.63 95% CI, p=0.041) in those vaccinated within the previous 1-5 months, and 0.38 (0.21-0.67 95% CI, p=0.001) in those vaccinated more than 6 months ago. 9 pts died, 5 were more than 6 months after the 2nd mRNA vaccine, 2 were unvaccinated and 1 patient received the booster on the same day of COVID19 diagnosis.

Conclusion

Before the vaccination campaign, the hospitalization and mortality rate in our cohort were similar to the data reported by other registries. COVID19 tends to be more severe, with increased mortality in patients with active AIIRD and visceral involvement (pulmonary, cardiac, renal), advanced age and co-morbidities. The delta outbreak occured 6 months after the implementation of vaccinations and was associated with significantly lower hospitalization and mortality rates, despite the increased aggressiveness of the variant. Vaccination of AIIRD pts with 3 doses of mRNA vaccines protects from severe COVID19 disease, hospitalization, and death.

Acknowledgements

Fadi Kharouf and Tali Eviatar had equal contribution

Disclosure of Interests

None declared

POS1245 REVERSAL OF DECLINE IN HUMORAL RESPONSE TO BNT162b2 mRNA COVID-19 VACCINE AFTER BOOSTER ADMINISTRATION IN AUTOIMMUNE INFLAMMATORY RHEUMATOID DISEASES (AIRD) PATIENTS

Background

Previous studies proved that mRNA vaccinations against SARS CoV2 induced significant humoral responses in AIRD patients (pts). However, the humoral response was blunted in pts treated with CD20 depleting antibodies. There are limited data regarding the long-term outcome of the humoral response and the contribution of the booster vaccine, in immunosuppressed AIRD pts.

Objectives

To assess the long-term outcome of the humoral response to mRNA vaccine against SARS CoV2, in AIRD pts treated with immunomodulating drugs, and the contribution of the booster vaccination.

Methods

Consecutive pts treated at the Rheumatology Institute at Rambam Hospital who received their first SARS-CoV-2 (Pfizer) vaccine were recruited to the study, at their routine visit. The visit included AIRD activity assessment and questioning regarding vaccine side effects. We performed serology test 4-6 weeks and 24 weeks after receiving the second dose of vaccine. Pts who received the booster (3rd vaccine) were invited for serology tests 4-8 weeks afterwards. The immunomodulating treatment was not modified, either before or after the vaccination. IgG Antibodies (Ab) against SARS COV2 virus were detected using the SARS-Cov-2 IgG II Quant (Abbott) assay based on a chemiluminescent microparticle immunoassay (CMIA) on the ARCHITECT ci8200system from Abbott. This assay is measuring IgG antibodies against the spike receptor-binding domain (S-RBD) of the virus. The test was considered positive above 50 AU/ml.

Results

262 pts (mean age(SD) 57(13), disease duration 11.2(7.4), were recruited. The cohort included 152 pts with inflammatory joint disease, 26 pts with systemic lupus erythematosus, 62 pts with other connective tissue disease and 22 pts with vasculitis; 27 % received csDMARDs only, 35% - b/tsDMARDs only, 30% - combined therapy (csDMARDs+b/tsDMARDs) and 26% received steroids. 225 pts (86%) were seropositive for IgG Ab against SARS CoV2 virus (median 2832.5 AU/ml, IQR 58-29499). 37 (14%) pts had negative tests, 23 (62.2%) of them were rituximab treated.

The IgG levels correlated with the medication used to treat the AIRD, the patients’ age but not with the type of the AIRD (Figure 1). 24 weeks afterwards, the median IgG level dropped to 282 AU/ml and 15% of the pts with previous seropositive tests became negative. The booster administration (Pfizer) significantly augmented the humoral response (median 8328 AU/ml, IQR 375-40000). De novo serologic response was observed in 10 out of 37 pts (4/23 rituximab treated pts).

Figure 1.

The reported side effects of the vaccine were minor (muscle sore, headache, low grade fever). The AIRD remained stable in all pts following all three vaccinations.

Conclusion

Although the vast majority of AIRD pts developed a substantial humoral response following the administration of the second dose of the Pfizer mRNA vaccine against SARS CoV2 virus, the humoral response significantly declined 24 weeks afterwards. An enhanced response was obtained after the third booster vaccination. Only minor side effects were reported and no apparent impact on AIRD activity was noted. Notably, 62% of the non-responders were treated with B cell depleting agents.

Acknowledgements

We would like to thank Mrs Tsofnat Margi and Mrs Sarit Elkouby for organisational support.

Disclosure of Interests

None declared

POS0831 IgA VASCULITIS IN ADULTS, PEDIATRICS AND NON-VASCULITIC IgA NEPHROPATHY

Background

IgA vasculitis (IgAV) has been extensively studied in children, while its natural history remains poorly studied in adults. Sparse data comparing childhood and adult-onset disease has shown significant differences in their clinical presentation, especially in the severity of renal involvement, which accounts for the major long-term morbidity. IgAV shares similar renal histologic features with IgA nephropathy (IgAN), while clinically IgAN is a chronic kidney disease which may lead to end stage renal disease and dialysis. The extent of kidney injury among adults with IgAV is still a matter of uncertainty.

Objectives

We aimed to evaluate clinical manifestations, laboratory data, treatment patterns and long-term outcomes of pediatric and adult-onset IgAV in comparison to IgAN.

Methods

This retrospective collaborative study examined medical records of adults and children with IgAV and IgAN adult patients admitted to rheumatology clinic and in hospital pediatric departments in a 13-year period (2007-2019). Diagnosis of adults with IgAV relied on the Ankara criteria and was confirmed by a consistent skin biopsy with positive IgA staining by immunofluorescence. Children with IgAV were included in our study on a clinical basis. All IgAN patients had a kidney biopsy proven disease. We analyzed and compared frequencies of clinical manifestations, laboratory findings, treatment regimens and long-term outcomes at one year follow-up. Finally, we assessed long term outcomes, such as time to dialysis and all-cause mortality, till the end of the follow-up time.

Results

A total of 60 adult IgAV, 60 pediatric IgAV and 45 IgAN patients were included in our study. There were significantly more males in the IgAN group compared to the adult and pediatric IgAV groups (77.8%, 41.7% and 55% respectively, p=0.01). Adult IgAV patients were significantly older than IgAN patients (53.1±17.4 years vs. 45.1±15.7 years, p=0.02) and had significantly higher rates of diabetes (43.3% vs. 24.4%, p=0.05) and ischemic heart disease (18.3% vs. 4.4%, p=0.03). The pediatric IgAV group had a statistically higher rate of previous infection compared to the adult IgAV group (44.8% vs. 20%, p=0.02). At one year follow-up, IgAN patients had higher levels of serum creatinine compared to the adult IgAV group (2.002 vs. 1.100, p<0.01). Data observed until the end of the follow-up time showed no difference in time to dialysis (IgAV adults: 9.8-12.4 years, IgAN: 5.0-6.6 years, p>.41). Nevertheless, IgAV adult patients had significantly shorter survival time (5.5 years, 95% CI: 4.8-6.2 years) than IgAN patients (7.0 years, 95% CI: 6.6-7.5 years, p<.01).

Conclusion

This retrospective study demonstrates that IgAV in adults presents substantial clinical manifestations, including high risk of progression to persistent renal impairment and possesses higher mortality rate in comparison with pediatric-onset disease and IgAN.

References

[1]Blanco R, Martínez-Taboada VM, Rodríguez-Valverde V, García-Fuentes M, González-Gay MA. Henoch-Schönlein purpura in adulthood and childhood: two different expressions of the same syndrome. Arthritis Rheum. 1997 May;40(5):859-64. doi: 10.1002/art.1780400513. PMID: 9153547.

[2]Nossent J, Raymond W, Isobel Keen H, Preen D, Inderjeeth C. Morbidity and mortality in adult-onset IgA vasculitis: a long-term population-based cohort study. Rheumatology (Oxford). 2021 Dec 24;61(1):291-298. doi: 10.1093/rheumatology/keab312. PMID: 33779729.

Figure 1.

Disclosure of Interests

None declared

POS0387 RISK STRATIFICATION APPROACHES PERFORM DIFFERENTLY IN SSc-ASSOCIATED PAH IN EUSTAR

Background

Pulmonary arterial hypertension (PAH) is a major clinical challenge in systemic sclerosis (SSc), and is associated with high mortality. Risk stratification provides an estimate for individual patient risk of 1-year mortality. The aim is to detect patients with the worst prognosis to optimize management strategies. Nine risk stratification approaches have been proposed in PAH, but have not been validated in SSc-PAH.

Objectives

To assess four risk stratification models and their performance to predict 1- and 3- year mortality and to identify the best risk assessment approach for SSc-PAH.

Methods

We included all patients with SSc diagnosed with PAH by right heart catheterization (RHC) from the European scleroderma trial and research (EUSTAR) database from 2001 to February 2021. PAH was defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure (PAWP) ≤15mmHg, and pulmonary vascular resistance (PVR) >3 Wood units (WU) in the absence of significant interstitial lung disease. We applied four different approaches for risk stratification at time of PAH diagnosis. Risk parameters included New York Heart Association (NYHA) class, 6-minute walk distance (6MWD), NT-proBNP or BNP, and echocardiographic and hemodynamic parameters with cut-off values based on the 2015 ESC/ERS Guidelines. Model 1 and 2 stratified patients into low, intermediate and high-risk categories; while Model 3 and 4 stratified the patients into four categories (low, intermediate-low, intermediate-high and high).

Model 1: Patients with ≥ 1 high-risk parameter were considered at high risk; with ≥ 1 intermediate-risk parameter at intermediate risk, otherwise at low risk1

Model 2: Each variable was graded from 1 to 3 representing low to high risk. The mean of available risk parameters was rounded to the nearest integer to define the risk category2

Model 3: Equals Model 2, but the intermediate risk group was divided into intermediate-low and intermediate-high based on the mean score3

Model 4: Stratifies patients into four risk categories based on the proportion of low-risk parameters3

We performed analysis of 1- and 3- year mortality in patients with a minimum follow-up of 1 and 3 years, respectively.

Results

Of 911 patients who conducted RHC, 273 (30%) were diagnosed with SSc-PAH according to the inclusion criteria (Table 1). Median follow-up time was 2.8 years (IQR 1.3-5.3). The models varied in their ability to predict mortality (Figure 1). Model 1 and 4 either over- or underestimated mortality. Model 2 stratified patients according to the expected 1-year mortality of <5%, 5-10% and >10% suggested by the ESC/ERS Guidelines. Model 3, which divided the intermediate risk group in two different risk groups, segregated the risk of mortality further within this group.

Table 1.

Demographic and clinical characteristics of patients segregated by risk stratification (Model 3)

NAll patients (n=273)Low-risk (n=78)Intermediate-low (n=118)Intermediate-high (n=56)High-risk (n=21)Age, years (SD)27365 (10.7)65 (10.3)65 (10.7)65 (10.8)67 (12.8)Female sex, n (%)273230 (84)64 (82)98 (83)48 (86)20 (95)lcSSc, n (%)263221 (84)60 (80)99 (86)47 (90)15 (71)NYHA 3 or 4, n (%)261155 (59)12 (16)75 (68)49 (89)19 (95)NT-proBNP, pg/ml (IQR)1111941 (230-1485)215 (103-377)763 (325-1418)1926 (1051-5681)3314 (1129-6553)6MWD, m (SD)196321 (124.1)404 (119.7)314 (99.9)262 (128.6)215 (96.0)RHC:- mPAP, mmHg (SD)27340 (11.0)35 (8.8)41 (11.5)41 (10.8)45 (11.6)- PAWP, mmHg (SD)2739 (3.2)9 (3.0)9 (3.4)9 (3.2)8 (3.1)- Cardiac index, l/min/m2(SD)2602.8 (0.8)3.2 (0.7)2.7 (0.8)2.6 (1.0)2.0 (0.5)- PVR, WU (SD)2737.4 (4.1)5.3 (2.8)7.9 (4.0)7.9 (4.2)11.3 (4.7)Figure 1.

1- and 3-year mortality according to risk category in the four different models

Conclusion

Model 3 provides signals for a better risk stratification of patients with newly diagnosed SSc-PAH, with progressively increasing mortality across the categories. This may provide guidance for optimized management in clinical practice.

References

[1]Hoffmann-Vold, Rheum 2018

[2]Kylhammar, Eur Heart J 2018

[3]Kylhammar, ERJ open 2021

Acknowledgements

The authors thank all EUSTAR collaborators.

Disclosure of Interests

Hilde Jenssen Bjørkekjær: None declared, Cosimo Bruni Speakers bureau: Actelion, Consultant of: Boehringer-Ingelheim, Patricia Carreira: None declared, Paolo Airò Speakers bureau: Boehringer Ingelheim, Bristol-Myers-Squibb, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Janssen, CSL Behring, Carmen Pilar Simeón-Aznar Speakers bureau: Janssen, Boehringer Ingelheim and MSD, Consultant of: Janssen, Boehringer Ingelheim, Marie-Elise Truchetet: None declared, Alessandro Giollo: None declared, Alexandra Balbir-Gurman: None declared, Mickael Martin: None declared, Christopher P Denton Speakers bureau: Boehringer Ingelheim; Janssen, Consultant of: Boehringer Ingelheim; GSK; Corbus; Sanofi; Roche; Horizon; CSL Behring; Acceleron, Grant/research support from: CSL Behring; Horizon; GSK; Servier, Armando Gabrielli: None declared, Håvard Fretheim Consultant of: Bayer, GSK, Actelion, Imon Barua: None declared, Helle Bitter Speakers bureau: Boehringer Ingelheim, Øyvind Midtvedt: None declared, Kaspar Broch: None declared, Arne Andreassen: None declared, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Gabriela Riemekasten: None declared, Ulf Müller-Ladner: None declared, Marco Matucci-Cerinic: None declared, Ivan Castellví: None declared, Elise Siegert: None declared, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

POS0140 PREDICTING OUTCOMES IN SYSTEMIC SCLEROSIS: STRATIFICATION BY AUTO-ANTIBODIES OUTPERFORMS CUTANEOUS SUBSETTING IN THE EUSTAR COHORT

Background

Risk-stratification is key in a heterogeneous disease like systemic sclerosis (SSc). Until now, SSc patients are stratified according to the extent of skin involvement into limited cutaneous, diffuse cutaneous and sine scleroderma subtypes. However, this classification remains inaccurate to capture disease heterogeneity. Autoantibodies are found in more than 90% of the patients and can be detected before onset of the disease. Among them, three predominant and specific antibodies are used: anti-centromere, anti-Scl70 and RNA polymerase III antibodies.

Objectives

To compare the performances of stratification into LeRoy’s cutaneous subtypes versus autoantibody status in SSc versus combination of cutaneous subtypes and autoantibodies status.

Methods

Patients from the EUSTAR database were classified either as (i) limited cutaneous, diffuse cutaneous or sine scleroderma (based on the recording made by the treating physician) or (ii) according to autoantibodies with the following subclassifications: (1) no specific autoantibodies, (2) isolated ANA, (3) anti-centromere antibodies, (4) anti-Scl70 antibodies and (5) anti-RNA polymerase III antibodies or (iii) according to combination of cutaneous subset and auto-antibodies. The respective performance of each model to predict overall survival (OS), progression-free survival (PFS), disease progression and different organ involvements was assessed and the three models were compared by the area under the receiver operating characteristic curve (AUC 95%CI) and the net reclassification improvement (NRI). Missing data were imputed through multiple imputation using chain equations.

Results

In all, 10’711 patients were included: 84.6% females, mean age: 54.4±13.8 years, mean disease duration: 7.9±8.2 years. In the prospective analysis (n= 6’467 to 7’829 according to the outcome), after a mean follow-up of 56 months and a mean of three visits per patient, we did not identify any difference in AUC between the cutaneous-based model and the antibody-based model for prediction of OS and disease progression. However, the NRI showed a significant improvement in prediction of OS (0.57 [0.46-0.71] vs. 0.29 [0.19-0.39]) and disease progression (0.36 [0.29-0.46] vs. 0.21 [0.14-0.28]) at 4 years using the antibody-based model. Regarding prediction of each organ involvement in longitudinal analyses, the antibody-based model showed better performance than the cutaneous-one for renal crisis (AUC: 0.719 [0.696-0.742] vs. 0.664 [0.643-0.685]), with the highest association observed with anti-RNA polymerase III (OR: 7.47 [1.63-34.24], p= 0.010). Similarly, the antibody-based model was better than the cutaneous model in predicting lung fibrosis (AUC 0.719 [0.715-724] vs. 0.653 [0.647-0.659]) and restrictive lung fibrosis (AUC 0.759 [0.749-0.766] vs. 0.711 [0.701-0.721]) which were both associated with anti-Scl70 antibodies (OR: 9.29 [8.17-10.55] and 7.92 [5.37-11.69], respectively, p<0.0001 for both). Although there was no difference in the AUC to predict digital ulcers, NRI showed an improvement using the antibody-based model (0.31 [0.29-0.33] vs. 0.24 [0.22-0.26]) with the highest association with anti-Scl70 antibodies (OR: 3.57 [2.68-4.75], p<0.0001). The two models had similar performances in assessing occurrence of intestinal involvement, heart dysfunction or elevated sPAP. Combining both antibody status and cutaneous subtype did not improve the performance of our models. In the exploratory analysis, there was no change using modified Rodnan skin score to define cutaneous form.

Conclusion

Auto-antibody status outperforms the common cutaneous subsetting to risk-stratify SSc patients in the EUSTAR cohort. This easily performed subclassification using autoantibodies specific status can be used by the clinicians to risk-stratify their patients and to adapt disease monitoring in routine practice.

Disclosure of Interests

Muriel Elhai Speakers bureau: BMS outside of the submitted work, Marouane Boubaya: None declared, Nanthara Sritharan: None declared, Alexandra Balbir-Gurman: None declared, Elise Siegert: None declared, Eric Hachulla: None declared, Jeska de Vries-Bouwstra: None declared, Gabriela Riemekasten: None declared, Jörg H.W. Distler: None declared, Douglas Veale: None declared, Edoardo Rosato: None declared, Francesco Del Galdo: None declared, Fabian A Mendoza: None declared, Daniel Furst Consultant of: Abbvie, Novartis, Pfizer, R-Pharm, Grant/research support from: Emerald, Kadmon, PICORI, Pfizer,Prometheus, Talaris, Mitsubishi, Carlos De la Puente Bujidos: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Armando Gabrielli: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Coralie Bloch-Queyrat: None declared, Yannick Allanore Consultant of: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis, Grant/research support from: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis

AB1236 CLINICAL CHARACTERISTICS OF JUVENILE ONSET SYSTEMIC SCLEROSIS PATIENTS FROM THE JUVENILE SCLERODERMA INCEPTION COHORT COMPARED TO ADULT AGE JUVENILE-ONSET PATIENTS FROM EUSTAR. ARE THESE DIFFERENCES SUGGESTING RISK FOR MORTALITY?

Background

Juvenile systemic sclerosis (jSSc) is an orphan autoimmune disease with a prevalence of 3 in 1 000 000 children. Information on long-term development of organ involvement and clinical characteristics of jSSc patients in adulthood are lacking. It was believed that patients in adult cohorts may represent a survival biased population.

Objectives

To assess differences in clinical characteristics of jSSc-onset patients from the pediatric age group, with a mean disease duration of 3 years, compared to the adult age jSSc-onset group, with a mean disease duration of 18.5 years.

Methods

We extracted clinical data at time of inclusion into the cohorts from the Juvenile Scleroderma Inception Cohort (jSScC) and data from juvenile-onset adult SSc patients from the European Trials and Research Group (EUSTAR) cohort. We compared the clinical characteristics of the patients by descriptive statistics.

Results

We extracted data of 187 jSSc patients from the jSScC and 236 patients from EUSTAR. The mean age at time of assessment was 13.4 years old in the jSScC and 32.4 years old in EUSTAR. The mean disease duration since first non-Raynaud was 3.0 years in jSScC and 18.5 years in the EUSTAR (Table 1).

We found significant differences between the cohorts. There were more female patients in EUSTAR (87.7% versus 80.2%, p=0.04). More patients had diffuse subtype in jSScC (72.2% versus 40%, p<0.001). The modified Rodnan skin score (mRSS) was significantly higher in jSScC (14.2 versus 12.1, p=0.02). Active digital ulceration occurred more often in EUSTAR (26.6%, versus 17.8% p=0.01), but history of active ulceration was more frequent in jSScC (54.1% versus 43%, p<0.001). Mean DLCO was lower in jSScC (75.4 versus 86.3, p<0.001). Intestinal involvement was significantly more common in jSSc (33.2% versus 23.8%, p=0.04). Esophageal involvement was more common in EUSTAR (63.7% versus 33.7%, p<0.001). (Table 1).

Table 1.

Clinical characteristics of juvenile onset SSc patients at time point of the inclusion into the juvenile scleroderma inception (jSScC) cohort and in the adult EUSTAR- cohort

jSScCEUSTAR CohortP valueNumber of patients1872360.04Age in years, mean (SD)13.4 (3.6)32.4 (15.4)Female patients, n (%)150 (80.2%)207 (87.7%)jSSC Subtype, n (%)diffuse135 (72.2%)87 (38.1%)<0.001limited52 (27.8%)121 (53.3%)Age at Raynaud onset in years, mean (SD)10.0 (3.9)13.7 (9.1)Age at non-Raynaud onset in years, mean (SD)10.3 (3.9)11.7 (3.7)Duration since first Raynaud symptoms in years, mean (SD)3.4 (2.7)20.6 (15.9)Duration since first non-Raynaud symptoms in years, mean (SD)3.0 (2.7)18.5 (15.6)Raynaud´s, n (%)170 (90.9%)222 (94.9%)ANA positive, n (%)166 (91.7%)210 (92.9%)0.99Anti-Scl 70 positive, n (%)62 (34.4%)73 (33.3%)0.68Modified Rodnan Skin Score, mean (SD)5%Data missingModified Rodnan Skin Score, mean (SD)14.2 (11.7)12.1 (14.5)0.02Digital ulceration, n (%)At the time of inclusion33 (17.8)21 (26.6%)0.01In the past history100 (54.1%)34 (43%)<0.001Telangiectasia62 (37.4%)42 (53.2%)0.04FVC, mean (SD)84.1 (18.6)84 (22.4)0.96DLCO, mean (SD)75.4 (19.2)86.3 (19.9)<0.001Arterial hypertension, n (%)10 (5.4%)20 (8.5%)0.26Renal crisis, n (%)03 (1.3%)0.26Esophageal involvement, n (%)63 (33.7%)149 (63.7%)<0.001Intestinal involvement, n (%)62 (33.2%)56 (23.8%)0.04Articular involvement, n (%)34 (18.3%)27 (11.6%)0.06Muscular involvement, n (%)31 (19.3%)46 (19.8%)0.45

Conclusion

Patients with jSSc-onset who are currently adult age (defined as >18 years of age) are less frequently male and from the diffuse subset, have lower mRSS, less digital ulcers and intestinal involvement. This might represent a combination of both survival bias and/or be explained by the longer observation time with less active disease (i.e. natural progression decreased mRSS over time). Further long-term observational studies with jSSc patients are required to address this issue.

Disclosure of Interests

None declared

Favourable outcome of planned pregnancies in systemic sclerosis patients during stable disease

Objective: Studies evaluating pregnancy outcomes in systemic sclerosis (SSc) are limited. SSc is associated with maternal complications and adverse neonatal outcomes. This study investigated the impact of disease stage (stable vs active) on the maternal and neonatal outcomes of pregnancies of patients followed at an Israeli medical centre.Method: The charts of 354 SSc female patients followed during 2003-2020 were reviewed. Data on clinical and laboratory features, number of pregnancies close to SSc diagnosis, and maternal and neonatal outcomes were analysed. Patients were divided into a stable disease and an active/early disease group.Results: The active/early disease group included 26 patients [19 diffuse SSc (dSSc)], with 38 pregnancies. Median disease duration was 1 year, except for four patients who were first diagnosed during pregnancy. SSc was exacerbated in all patients during pregnancy or shortly after delivery [skin, lung, and heart involvement in dSSc; severe vasculopathy in limited SSc patients]. Six patients had hypertensive disorders of pregnancy; four pregnancies ended with foetal death. Thirty-three children were born, 60% with intrauterine growth retardation (IUGR)/low birthweight (LBW). The stable disease group included 19 patients, including seven with previously active disease, now stabilized (five dSSc), and 32 pregnancies. All pregnancies were planned and monitored closely. Disease remained stable in all patients. Four patients had hypertensive disorders of pregnancy; 12/29 newborns had LBW (41%).Conclusion: Active maternal disease during pregnancy poses an increased risk of SSc aggravation. The maternal and neonatal outcomes in planned pregnancy during stable disease are favourable. IUGR/LBW is common among neonates, even in stable disease.

POS0318 CLINICAL PHENOTYPE IN SCLERODERMA PATIENTS WITH ANTI-TOPOISOMERASE I POSITIVITY AND LIMITED CUTANEOUS FORM: DATA FROM THE EUSTAR DATABASE

Background:

There is renewed interest in the role of autoantibodies to predict outcomes in systemic sclerosis (SSc). Among the newly identified subsets, patients with limited cutaneous form (lcSSc) but anti-topoisomerase I antibodies (Scl70) positivity draw particular attention, and namely, assessing the risk of developing interstitial lung disease (ILD) —the main cause of death in SSc—to improve the management of Scl70-lcSSc patients.

Objectives:

We aimed to characterize patients with Scl70-lcSSc in the large multicenter European Scleroderma Trial and Research (EUSTAR) cohort.

Methods:

The EUSTAR database was locked in July 2019. We included all patients fulfilling 1980 ACR and/or 2013 ACR/EULAR criteria for SSc, with disease duration at database entry ≤3 yrs and known and stable skin form during the first 3 yrs. Patients with lcSSc were compared: Scl70-lcSSc (target group) vs. ACA-lcSSc and ANA-lcSSc (Step 1); and Scl70-lcSSc vs. Scl70-dcSSc (Step 2). In the ANA subgroup we included ANA+ patients with negative SSc-specific antibodies (Scl70, ACA, RNA polymerase III). In each step, we performed 5 generalized mixed models (GMM) for the risk of the new onset of ILD (defined by imaging), primary myocardial involvement (PMI), pulmonary hypertension (PH), “any severe” (ILD+PMI+PH+scleroderma renal crisis) and all-cause-mortality. An additional GMM assessed the risk of forced vital capacity (FVC) decline ≥10% vs. FVC value at ILD onset. Each GMM was adjusted for age, sex and confounders.

Results:

Overall, 1285 SSc patients were included: 1068 (83%) females, 860 (67%) lcSSc and 425 (33%) dcSSc. Among patients with lcSSc, 537 (62%) had ACA+, 194 (23%) Scl70+ and 129 (15%) ANA+; 425 patients had dcSSc and Scl70+. Median follow-up was similar in all 4 groups: 7.2 to 8.1 yrs.

Step 1: At baseline, Scl70-lcSSc patients had significantly shorter time from Raynaud’s phenomenon (RP) to SSc onset, higher mRSS (5.8±4.8 vs. 4.3±4, p=0.001), and higher rate of articular and muscular involvement vs. ACA-lcSSc patients (Figure 1). No differences were found between Scl70-lcSSc and ANA-lcSSc comparing the aforementioned variables. ILD was more frequent in Scl70-lcSSc (46%) than in ACA-lcSSc (10%) and ANA-lcSSc (25%), as well as restrictive lung disease. GMM showed that Scl70-lcSSc carries a higher risk of ILD than both ACA-lcSSc (HR 4.55, 95%CI 3.23-6.67) and ANA-lcSSc (HR 2.17, 95%CI 1.39-3.45), with a rate of FVC decline ≥10% over time similar to the other limited forms. In Scl70-lcSSc patients the risk of “any severe” organ involvement was similar to ANA-lcSSc and higher than ACA-lcSSc (HR 1.89, 95%CI 1.40-2.50). In particular, Scl70-lcSSc shows a risk of PMI similar to ANA-lcSSc and lower than ACA-lcSSc; no differences regarding PH risk. The mortality risk in patients with Scl70-lcSSc was similar to the other limited forms’.

Step 2: At baseline, time from RP to SSc onset was longer in patients with Scl70-lcSSc, with less frequent joint synovitis and tendon friction rubs vs. patients with Scl70-dcSSc. Conversely, the frequency of muscular, cardiac and pulmonary involvement was similar. The risk of ILD in Scl70-lcSSc patients was similar to Scl70-dcSSc, with a lower risk of FVC decline ≥10% over time. The risk of “any severe” involvement (HR 0.66, 95%CI 0.49-0.83), PMI and PH was lower and the mortality risk tended to be lower (HR 0.57, 95%CI 0.33-1.01, p=0.053) vs. Scl70-dcSSc.

Conclusion:

In our large multicenter EUSTAR cohort one quarter of lcSSc patients were Scl70+. We show a ranking for major organ involvement within lcSSc: Scl70 the most severe, ANA+ intermediate and ACA the milder form. Scl70-dcSSc patients present the most severe phenotype, and Scl70 positivity, more than the cutaneous subset, is strongly predictive of ILD, whereas other variables may influence progression. These results may provide new insight to improve the management of Scl70-lcSSc patients.

Disclosure of Interests:

Elisabetta Zanatta: None declared, Dörte Huscher: None declared, Paolo Airò: None declared, Alexandra Balbir-Gurman: None declared, Elise Siegert: None declared, Augusta Ortolan: None declared, Marco Matucci-Cerinic: None declared, Franco Cozzi: None declared, Gabriela Riemekasten: None declared, Anna-Maria Hoffmann-Vold: None declared, Oliver Distler Speakers bureau: has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: Kymera Therapeutics, Mitsubishi Tanabe, Armando Gabrielli: None declared, Stefan Heitmann: None declared, Nicolas Hunzelmann: None declared, Carlomaurizio Montecucco: None declared, Jadranka Morovic-Vergles: None declared, Camillo Ribi: None declared, Andrea Doria: None declared, Yannick Allanore: None declared

POS0871 CHARACTERISTICS OF INTERSTITIAL LUNG DISEASE IN PATIENTS WITH SYSTEMIC SCLEROSIS DURING LONG TERM FOLLOW-UP, SINGLE CENTER EXPERIENCE

Background:

ILD is one the leading causes of morbidity and mortality in patients with SSc. Diagnosis of SScILD is based on signs of fibrosis on chest x-rays or HRCT. Particular measurement of lung volumes by FVC and in gas exchange by DLCO supports the diagnosis. Associations between clinically significant SSc ILD and male gender, age, DcSSc, topoisomerase antibodies, low FVC at baseline, widespread lung involvement on baseline HRCT, and higher decline rate of FVC and DLCO during followup were reported. A standardized approach to assessing and treating SSc and SScILD in particular have been proposed. Main treatment regimens include cyclophosphamide and mycophenolate mofetil; recently antifibrotic drug nintedanib showed significant efficacy in hindering FVC decline rate in patients with SSc ILD. The data on survival changes in SSc generally and SScILD are conflicting.

Objectives:

To analyze demographic and clinical features and mortality of patients with SSc ILD.

Methods:

A retrospective study on Rambam Health Care Campus prospective cohort of SSc patients fulfilled ACR and EULAR Classification Criteria 2013 for the period between January 2000 and September 2020 was performed. Patients were recruited at one of their early visits to the clinic. The majority of recruited patients were included into EUSTAR prospective cohort 042, since 2004 the Rheumatology Institute at Rambam is affiliated to EUSTAR registry project. Data on patients not registered in EUSTAR database but treated at our institution was extracted via hospital electronic records. Patients with lung involvement underwent baseline and annual HRCT and pumonary function tests in addition to clinical assessment during their visit to combined rheumatology-pulmonology clinic. We registered age, gender, ethnicity, date of SSc diagnosis and ILD diagnosis, disease duration, SSc subset, pulmonary, cardiac, renal, and muscle involvement, treatment used, autoantibodies, FVC, DLCO, HRCT and pulmonary artery pressure. Statistical analysis included t-test, Pearson’s Chi-squared test, Fisher’s test, and Cox Regression analysis with p value less than 0.05 as significant.

Results:

Among 446 SSc patients (female 82.3%, mean age 46.5 and disease duration 11.6 years, DcSSc 39.2%; 27.4% dead during follow-up) 141 patients had ILD. Comparison between patient with ILD and witout ILD showed significant differences in term of nationality (Arabs 34% vs 18.7%), SSc related death 78.3% vs 50.7%), DcSSc (68.8% vs 25.6%), topoisomerase antibodies (61.7% vs 24.9%), myopathy (21.3% vs 10.2%) and pulmonary hypertension (34.8% vs 22.3%). Significantly more SSc ILD patients were treated with cyclophosphamide, mycophenolate mofetil and azathioprine. Survival Kaplan-Meier curve patiets demonstrate reduced survival in patients with ILD (p<0.01). Five years survival rates between years 2000 and 2015 have not changed significant. Mortality risk assessed with Cox regression analysis in the whole group was significantly higher in males, Arabs, DcSSc, elder age, heart and muscle involvement, and treatment with CYC. In the ILD group, the mortality was significantly higher in Arabs (3.3 times), elder age (8.9 times), presence of PAH (3.1 times) and treatment with CYC (2.8 times) compared to patients without ILD.

Conclusion:

In our SSc cohort, ILD affected about third of patients and had major impact on patients’ outcome. Male gender, Arab nationality, elder age, DcSSc, topoisomerase antibodies, heart and muscle involvement were significantly associated with worst prognosis. Despite active approach to assessing and treatment, survival rates of patients with SSc and SSc-ILD have not improved in last decades. Enrichment of the cohort with severe patients to a tertiary center due to reference bias and low efficacy of existed immunomodulatory drugs in SSc and in SSc related ILD particularly, could explain our results.

Disclosure of Interests:

None declared

POS1217 THE PATTERN OF COVID 19 PANDEMIC AMONG PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES (AIIRD)

Background:

The epidemiology of COVID19 among patients with AIIRD may be influenced by a dysregulated immune system, immunosuppressive therapies and behavioral patterns. Data regarding the epidemiology of COVID19 among patients with AIIRD is scarce.

Objectives:

To assess the pattern of COVID19 pandemic among patients with AIIRD compared to the general population in Israel

Methods:

At the beginning of the COVID-19 pandemic, we established a national registry of patients with AIIRD, diagnosed with COVID-19, based on voluntary reporting by the treating rheumatologist. All the members of the Israeli Society of Rheumatology were encouraged to participate and repeatedly reminded to report any new cases. Rheumatology centers from 11 hospitals from the Northern and Central part of Israel participated in this study. The registry included demographic data, AIIRD diagnosis and duration, systemic organ involvement, co-morbidities, treatment (conventional synthetic disease modifying drugs (csDMARDs), biologic/targeted (b/ts) DMARDs, corticosteroids use, dose and treatment duration, date of COVID19 diagnosis, severity of the viral disease and complications, duration of hospitalization, if required, treatment for COVID 19, laboratory results and outcome. The diagnosis of COVID 19 was made by a positive SARS CoV2 PCR. The indications for SARS CoV2 PCR testing in Israel comprise clinical symptoms or exposure to a confirmed close contact. Severe illness was defined by SpO2 <94% in room air, respiratory rate of >30 breaths/min, PaO2/FiO2 <300 mm Hg, or lung infiltrates >50% on chest imaging.

The epidemiological data regarding the number of COVID19 confirmed patients, the number of severe cases and the rate of mortality among the general population per day and per week, were extracted from the data dashboard of the Israeli Ministry of Health. We analyzed data from 02.2020 to 15.01.2021.

Results:

During the study period we experienced 3 waves of COVID 19 pandemic. The governmental management of COVID19 spread, at the beginning of the pandemic, included inforcement of severe travel restrictions and social distancing, followed eventually by a preventive lockdown, in spite of the relatively low number of cases. Easing of the restrictions, lifting the travel ban, opening of the commerce and schools led to 2 much more severe waves, which triggered 2 new lockdowns. Up to January 2021, 549763 Israelis had confirmed COVID19, 30% of whom had severe disease, 0.84% died (30% of the patients with severe disease).

We identified 190 AIIRD patients (mean(SD) age 52(18), 30% males) who had confirmed COVID19. The weekly incidence curve of patients with rheumatic diseases correlated with the curve of the general population (Figure 1).

Sixty-one % of the patients with AIIRD received csDMARDs, 41% were on b/tsDMARDs, 39% on chronic corticosteroids, 12% on ≥10mg prednisone. Forty-seven% of patients required hospitalization, 20% had severe COVID19. Sixteen patients (42% of patients with severe COVID19) (mean(SD), median age 64.7(15.4),67)) died (systemic sclerosis-4 patients, rheumatoid arthritis – 6, systemic lupus erythematosus – 2, antiphospholipid syndrome-2, granulomatous polyangiitis -1, polymyalgia rheumatica-1). The AIIRD was active in 56% of them, 50% received csDMARDs, none of them were on b/tsDMARDs, 31% received chronic prednisone>10 mg. All patients who died had at least 2 comorbidities.

Conclusion:

The pattern of spread of COVID19 in AIIRD patients is similar to the general population despite repeated mass media alerts for enhanced social distancing for elderly and immune suppressed patients. The disease tends to be more severe with enhanced mortality, especially in those with active AIIRD disease and organ involvement (lungs, heart, renal), older age and co-morbidities. A reporting bias cannot be excluded.

Figure 1.

Acknowledgements:

Both first authors contributed equally to the manuscript.

Disclosure of Interests:

None declared.

POS0974 IMPROVEMENT IN THE DIAGNOSTIC DELAY OF AXIAL SPONDYLOARTHRITIS, RESULTS FROM REAL WORLD DATA

Background:

Diagnostic delay is a major challenge in axial spondyloarthritis (axSpA) with an extended interval of 8-10 years in Europe and 14 years in the United States between symptom onset and disease diagnosis (1, 2).

Objectives:

To assess the delay in the diagnosis of axSpA over time in a real world axSpA cohort diagnosed in the last 3 decades and to evaluate factors associated with this delay.

Methods:

A cohort of axSpA patients was recruited from a national multicenter registry of inflammatory arthritis. This cohorts’ demographic, clinical and diagnostic variables were studied. The diagnostic delay was defined as the time interval between the year of first symptom and year of diagnosis. The mean and median diagnostic delay were calculated. A survival analysis was performed evaluating the association between the demographic, clinical and diagnostic variables on the diagnostic delay.

Results:

Of the 373 axSpA patients in the registry, 198 (47%) are men. Ankylosing spondylitis fulfilling New York criteria was diagnosed in 73% of the patients. HLA-B*27 positivity was found in 64% of patients. The majority of the patients (63%) reported symptom onset between the age of 21-45, 21% before the age of 21 and 16% after the age of 45. Nine percent were diagnosed before the age of 21, 28% between 21-30, 23% between 31-40, 21% between 41-50 and 18% after the age of 50. One hundred and ten patients were diagnosed before 2000, 133 between 2001-2009 and 130 between 2010-2020. The mean and median delay in diagnosis was 9.1, 6 (±8.4) years when diagnosed before 2000, 5, 4 (±4.1) years when diagnosed 2001-2009, and 2, 1 (±1.5) years when diagnosed 2010-2020, respectively (graph 1). The only variable which was found to be associated with a shorter delay was the interval between symptom onset and first rheumatology consult: HR of 5.86 (4.3-8, p<0.001) if the rheumatology visit was within the first year of symptoms, HR 3.5 (2.4-5, p<0.001) if assessed 2-3 years after symptom onset. Additionally, age <21 at symptom onset was associated with a shorter delay (p=0.005). Sex, type of axSpA (radiographic vs. non radiographic axSpA), level of education, and HLA-B*27 positivity were not associated with a delay in diagnosis.

Conclusion:

Delay in axSpA diagnosis has significantly improved in this real-world cohort during the last decade. The most significant factor associated with a faster diagnosis was the time of the first rheumatology consult relative to symptom onset. Increasing the awareness of disease manifestations and early referral to a rheumatology service can improve the diagnosis delay of axSpA.

References:

[1]Sorensen J, Hetland ML, all departments of rheumatology in D. Diagnostic delay in patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis: results from the Danish nationwide DANBIO registry. Ann Rheum Dis. 2015;74(3):e12.

[2]Deodhar A, Mittal M, Reilly P, Bao Y, Manthena S, Anderson J, et al. Ankylosing spondylitis diagnosis in US patients with back pain: identifying providers involved and factors associated with rheumatology referral delay. Clin Rheumatol. 2016;35(7):1769-76.

Graph 1.

The improvement in the delay in diagnosis of axial spondyloarthropathy over the last 3 decades

Disclosure of Interests:

None declared.

THU0340 DURATION AND SYSTEMIC SCLEROSIS SUBTYPE ARE ASSOCIATED WITH DIFFERENT GUT MICROBIOME PROFILES

Background:

A growing body of evidence suggests that the gut microbiota plays a significant role in the development of autoimmune diseases. Altered microbiota composition was associated with gastrointestinal and extraintestinal features in systemic sclerosis (SSc) patients.

Objectives:

To look for differences in gut microbiota between SSc patients regarding disease duration, disease subset and occurrence of digital ulcers (DU).

Methods:

SSc patients seen at our center were recruited in a prospective study. The exclusion criteria included antibiotic or probiotic treatment during the month prior to recruitment, recent hospitalization, BMI>30, diabetes mellitus or concomitant inflammatory bowel disease. Fecal samples were processed and 16S rRNA gene sequences were analyzed using the QIIME2 packageWeighted (quantitative) and unweighted (qualitative) UniFrac distances, alpha diversity for richness and homogeneity, taxa plots for species and phyla and ANCOM analyses were performed.

Results:

During July 2018-May 2019, 26 SSc patients (mean age [SD] 53[12.7] years) and disease duration 8.8 [7.1] years) fulfilled the criteria and were willing to participate in the study. Thirteen patients had diffuse SSc, 16 patients had active DU, 8 patients had Raynaud’s phenomenon only without DU, 2 patients had past DU. The microbiota was significantly more similar between patients without active DU compared to those with active DU (P=0.024), but species richness did not differ. Patients with SSc duration less than 6 years had significantly different microbiota compared to long-lasting SSc (unweighted PCoA – q=0.031). Significant variations concerning quantitative and qualitative UniFrac distances (q=0.063, q=0.005) and species richness (q=0.009) were found among patients with diffuse compared to limited SSc. Limited SSc was associated with greater species richness. Taxa plot analysis revealed higher relative abundance of Firmicutes in diffuse disease and of Actinobacteria and Bacteroidetes in limited SSc.

Conclusion:

Disease duration, disease subset and active DU were associated with shifts in the microbiome of SSc patients. The impact of these changes on disease progression needs further elucidation.

Figure:

Disclosure of Interests:

Yolanda Braun-Moscovici: None declared, Shira Ben Simon: None declared, Katya Dolnikov: None declared, Sami Giryes: None declared, Doron Markovits: None declared, Yonit Tavor: None declared, Kohava Toledano: None declared, Alexandra Balbir-Gurman Consultant of: Novartis, Omry Koren: None declared

AB0181 COULD TITERS OF ACPA PREDICT THE SEVERITY OF RHEUMATOID ARTHRITIS, ANALYSIS OF DATA DURING A 3-YEARS FOLLOW-UP?

Background:

Rheumatoid Factor (RF) and/or Anti Citrullinated Protein Antibodies (ACPA). Are included in classification criteria of Rheumatoid arthritis (RA); their presence correlates with RA severity. The influence of ACPA titer on RA course and outcome in long-term follow-up is limited.

Objectives:

To check the correlation between ACPA titers at the time of RA diagnosis to RA features and severity during 3 years follow-up.

Methods:

We performed a retrospective study on patients treated at our institution during the years 2006-2015 with known ACPA titers at RA diagnosis, who completed at least 3 years of follow-up. Patients (pts) were divided according to ACPA titer: A - seronegative (<15 U/ml), B - weak positive (15-49 U/ml) and C - strong positive (>50 U/ml) with subdivision to C-1 - moderately high (50-99 U/ml), C-2 - high (100-299 U/ml) and C-3 - very high (>300 U/ml). Patient’s data including DAS28, bone erosion on hands and/or foot X-rays, treatments with corticosteroids and DMARDs and hospitalizations due to flares. Chi-Square and Mann-Whitney method were used for statistical analysis; p<0.05 was considered statistically significant.

Results:

Among 850 pts with RA, 133 (mean age 55 years, 65% female) met the inclusion criteria: group A: 55 (42%) pts, group B: 18 (13%) pts, group C: 60 (45%) pts [C1- 10 pts, C2-21 pts and C3-29 pts]. Most of the characteristics were similar between the groups (including C subgroups). There were no significant differences between the groups in terms of tender and/or swollen joints, acute phase reactants, bone erosions, need for corticosteroids or DMARDs, hospitalizations, number of DMARDs and number of biologicals. There was significant correlation between ACPA titers and positive RF (p<0.0001); it was consistent in all patients groups. Higher ACPA titers were associated with greater percentage of patients with positive RF. The percentage of male was higher in subgroup with highest ACPA: 25% in ACPA-negative group compared to 45% in the strong positive group (group C-3); it correlated with current or ever smoking. DAS28 was high in all groups without significant difference; over 80% of patients had DAS28 higher than 3.2 and 50-60% had a value higher than 5.2. During the 3-year follow-up, 95% of pts received prednisone with an average daily dose of 14.8 mg (SD, 8.9 mg), 50% of pts received more than 15 mg prednisone daily. The average number of synthetic and biological DMARDs was 2.5 (SD 0.73) and 0.56 (SD 0.84) per patient; methotrexate was prescribed in 89% of cases. There were no correlations between negative (group A) or positive ACPA (group B and C) and the variables defined as representing the severity of RA: the percentage of pts with DAS28>3.2 (p=0.136) and DAS28>5.2 (p=0.774). The percentage of pts receiving prednisone dosage higher than 15 mg/day (p=0.828) or at least two synthetic (p=0.846) or biological DMARDs (p=0.668) or their combination (p=0.770) were not significantly different. There was no correlation between ACPA titer and bone erosions (87 pts, p=0.883) during 3 years of follow-up. Finally, there was no correlation between ACPA titers and the number of hospital admissions (p=0.951).

Conclusion:

In our cohort of RA pts, higher ACPA titers were observed in males with smoking history. Higher ANCA titers correlated with RF positivity but were not identified as predictive factor for RA severity.

Disclosure of Interests:

Rotem Shpatz: None declared, Yolanda Braun-Moscovici: None declared, Alexandra Balbir-Gurman Consultant of: Novartis

OP0013 SINGLE CELL PROFILE OF SKIN STROMAL AND IMMUNE CELLS AND PERIPHERAL BLOOD IMMUNE CELLS OF SCLERODERMA PATIENTS TOWARDS IDENTIFICATION OF DISEASE MECHANISM, PROGNOSTIC BIOMARKERS AND POTENTIAL THERAPEUTIC TARGETS

Background:

Despite many years of research, our understanding of Systemic Sclerosis (SSc) pathogenic processes, patient-to-patient variability, and diversity of stromal and immune cells within the involved tissues microenvironment, their interaction, as well as the genes and pathways leading to the pathogenesis remains largely unclear. Current technologies for characterizing SSc have limited depth and resolution, which needed for molecular define the small skin stromal and immune cells sub-populations supposed to drive SSc pathogenesis. Single-cell sequencing technologies hold a great potential in genomic medicine since they offer high resolution and sensitivity for unbiased profiling of disease versus normal niches.

Objectives:

Comprehensive characterization of stromal and immune cells in the skin and blood of SSc patients, and healthy controls, their specific intra-skin cell states, pathways, cell-cell interactions, and unbiased characterization of cell types profile, biomarkers, drivers, and regulatory pathways associated with specific SSc patient subgroups.

Methods:

We applied the massively parallel single cell RNA-seq (MARS-seq) developed in our laboratory to conduct a comprehensive single-cell genomics analysis of skin stromal and immune cells obtained through punch biopsy and blood immune cells from 73 SSc patients (39 DcSSc, 34 LcSSc) and 30 healthy controls. We used the MetaCell analytical method to identify homogeneous and robust groups of cells from single cell RNA-seq data. The perturbed signaling pathways, pathogenic stromal or immune cell subsets are characterized using CyTOF, immunohistochemistry,PhysicalInteractingCell sequencing (PIC-seq), andin vitrofunctional assays.

Results:

We collected data from a total of 46,742 high-quality skin stromal cells, and 57,475 high-quality blood and skin immune cells. Analysis of stromal cell compartment led to a detailed map of 261 meta cells organized into 16 broad lineages including: Fibroblasts, Pericytes, Vascular cells, and other cells. In the immune cell compartment, we found 361 meta cells organized into 14 broad lineages (e.g unique skin T, B, NK and dendritic cells). We observed a unique population of stromal and immune cells in the skin and blood of SSc patients as compared to controls. The major and dramatic changes were observed in the stromal cell compartment of the patient’s skin compared to controls. In the fibroblast lineage we found a small cluster of cells that were significantly diminished in the SSc patients compared with control, expressed genes associated with fibrosis and vascular remodeling. Significantly higher number of specific subsets of pericytes and vascular cells was found in SSc patients compared to controls. Analysis of the immune cell compartment revealed only minor changes in the immune cell composition in patients compared with controls. Finally, we found known and novel pathways (e.g Wnt/Notch signaling, IFN type I/II, AP-1 pathway, complement cascade activation) and cell-cell interactions that play crucial roles in SSc pathogenicity.

Conclusion:

Our study provides a detailed and unprecedented high-resolution atlas of the immune and stromal cells that make up the skin and peripheral blood in a large cohort of SSc patients with diverse disease duration and clinical settings. Our findings of candidate stromal and immune cell subpopulation, genes and pathways constitute the basis for understanding of SSc pathogenesis and heterogeneity and holds great potential to provide clinicians with new and powerful molecular tools for understanding of the immune-stromal cell crosstalk, for finding new biomarkers for SSc activity and complications and for tailoring and identification of new therapeutic targets.

Disclosure of Interests:

Chamutal Gur: None declared, Alexandra Balbir-Gurman Consultant of: Novartis, Hagit Peleg: None declared, Suhail Aamar: None declared, Fadi Kharouf: None declared, Yolanda Braun-Moscovici: None declared, Shuang-Yin Wang: None declared, Ido Amit: None declared

FRI0337 REAL WORLD SECUKINUMAB DRUG-SURVIVAL IN PSORIATIC ARTHRITIS

Background:

Secukinumab (Cosentyx) is a human IgG1 monoclonal antibody that selectively binds to and neutralizes IL-17A. Several prospective randomized control trials have demonstrated the efficacy and safety of secukinumab in PsA, but there is a paucity of real life data in the PsA population.

Objectives:

To prospectively study secukinumab’s safety, efficacy, and tolerability in the cohort of PsA patients from the Israeli registry of inflammatory diseases.

Methods:

PsA patients fulfilling the CASPAR criteria from the Israeli registry of inflammatory diseases were included in the analysis, from 2010 to November 2019. The primary end point was secukinumab drug survival compared to other available TNFi drug. Bivariate and multivariate analysis of the factors that affect the drug event free survival was done by cox regression analysis. Drug survival according to treatment line (all treatment lines, or 2ndand above treatment lines) was examined using Kaplan-Meier curves.

Results:

Four hundred and four PsA patients were included, which had 709 treatment episodes (initiations) during the study period. Ninety patients had been treated with secukinumab (22%). Secukinumab treated patients were significantly older at time of initiation of treatment, and disease duration was longer. Secukinumab was more likely to be a second, third or forth line of treatment than the TNFi. . Time to an inefficacy event was longer for secukinumab than any other anti-TNF treatment. As a first line treatment secukinumab had drug survival similar to other TNFi. As a second or third line treatment, secukinumab had a better drug survival than other TNFi. Methotrexate did not have a significant effect on inefficacy event rate in combination treatment with secukinumab. Secukinumab, as infliximab and golimumab, was as effective in the higher BMI group as it was in the normal weight to obese groups. Smokers (current or past) did better on secukinumab than on TNFi. Secukinumab had a similar rate of adverse events compared to TNFi.

Conclusion:

In this multicenter real world study, secukinumab had a comparable drug survival to TNFi. As a second and beyond line of treatment secukinumab had a better drug survival and lower HR for an inefficacy event. IL-17 inhibition is an effective mechanism of action to treat PsA in real life, and should be used more frequently as a first and second line treatment.

Tables and a graph:

Table 1.

Inefficacy events according to treatment and drug survival in 1, 2, and 3 years.

DrugTotal episodesInefficacy events (%)HR95% CIP value1styear survival %2ndyear survival %3rdyear survival %SEC9030 (33.3)10.095865841ETA20286 (42.6)1.160.77-1.760.479755850IFX8734 (39.1)1.010.62-1.650.966826452ADA227103 (45.4)1.360.9-2.040.143715346GOL103103 (50)1.641.05-2.590.031635042Table 2.

inefficacy events and drug survival according to line of treatment.

DrugTotal episodesInefficacy events (%)HR95% CIP value1styear survival %2ndyear survival %3rdyear survival %1stlineSEC132 (15.4)10.216929276ETA13055 (42.3)3.250.79-13.340.101765951IFX2811 (39.3)2.880.64-13.010.168816352ADA10337 (35.9)2.630.63-10.910.183796359GOL2514 (56)4.551.03-200.0456050402ndand 3rdlinesSEC347 (20.6)10.039906666ETA6829 (42.6)1.680.74-3.850.218735751IFX5120 (39.2)1.420.6-3.360.431856454ADA11962 (52.1)2.51.15-5.480.022654635GOL5223 (44.2)2.260.97-5.270.066550464thlineSEC4321 (48.8)10.082824424ETA42 (50)1.10.25-4.730.9026733–IFX83 (37.5)0.830.25-2.790.7626969–ADA54 (80)4.871.6-14.810.00530––GOL2613 (50)1.290.64-2.580.473625231Figure 1.

Cumulative survival without an inefficacy event of secukinumab compared to TNFα inhibitors regardless of treatment line.

Disclosure of Interests:

Tali Eviatar: None declared, Devy Zisman Consultant of: Novartis, Merav Lidar Consultant of: Novartis, Tatyana Reitblat Consultant of: Novartis, Alexandra Balbir-Gurman Consultant of: Novartis, Ori Elkayam Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Novartis, Jansen

AB0549 THE RELEVANCE OF AORTIC STENOSIS AND OUTCOME OF TAVI PROCEDURE FOR VALVE REPAIR IN SCLERODERMA PATIENTS

Background:

Patients with systemic sclerosis (SSc) are at risk for developing aortic valve changes. The prevalence of aortic valve stenosis (AS) in SSc patients is unknown. Previously, patients with AS were treated with valve replacement; in recent years, Trans Catheter Aortic Valve Implantation (TAVI) is widely used in general population. The safety of Trans Catheter Aortic Valve Implantation (TAVI) in SSc has not been assessed.

Objectives:

A retrospective study on aortic valve pathology and treatments including TAVI performance.

Methods:

We reviewed 374 records of SSc patients at our site EUSTAR cohort and extracted cases with reported AS confirmed by ECHO cardiography and heart catheterization.

Results:

We found data on 13 (3.4%) patients with AS: 12 females (92.3%); mean age 70.3 (SD 7.7) years, disease duration 15.4 (SD 6.3) years. Ten patients had limited SSc (76.9%, all cared anti-centromere antibodies) and 3 diffuse SSc (1 patient had RNAP3 and 2 had anti-topoisomerase antibodies); 5 (38.5%) patients had significant coronary disease (3 underwent CABG, 2 had several PTCA). Eight (61.5%) patients dead during years 2004 - 2019. Aortic valve replacement was performed in 5 patients (4 – metal and 1 – biological); 2 patients did not undergo AS repair due to impaired general condition; 6 patients underwent TAVI between January 2013 and December 2019 (5 at Rambam Cardiology Institute). All SSc patients underwent trans femoral TAVI under conscious sedation. The procedure was successful in all patients. The length of hospitalization was 5-14 days (mean 8.2 days); 3 (50%) patients needed pacemaker implantation (they did not have previous conduction abnormalities). The follow-up duration after TAVI was between 5 and 67 months (mean 20.7). During follow-up one patient developed bacterial endocarditis related to pacemaker device two months after the procedure; the event resolved after removing the device and according antibiotics treatment; the same patient had transient ischemic attack two years later and another pacemaker implantation 3 years later due to complete AV block. One patients dead from urosepsis 11 months after TAVI, the death was not related to procedure. One patient developed anemia due to large hematoma after the procedure.

Conclusion:

Screening for aortic valve pathology is essential as AS is not rare in SSc patients especially in those with long standing limited disease and positivity to centromere antibodies. AS in SSc patients may be associated with clinically significant coronary artery disease. TAVI was safe in our SSc patients without in-hospital mortality and benign long-term outcome.

Disclosure of Interests:

Alexandra Balbir-Gurman Consultant of: Novartis, Yolanda Braun-Moscovici: None declared

THU0458 HIGH PREVALENCE OF JOINT HYPERMOBILITY IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH PAIN UNRESPONSIVE TO BOWEL-TARGETED THERAPY

Background:

Musculoskeletal manifestations occur in 20-50% of patients (pts) with inflammatory bowel disease (IBD). A substantial number of patients complain of non-inflammatory musculoskeletal pain.

Objectives:

To assess the incidence of joint hypermobility (JHM), benign joint hypermobility syndrome (BJHS) among patients with inflammatory bowel disease (IBD) examined in the inter-disciplinary rheumatology service at a tertiary referral center and the impact on IBD manifestations and outcome.

Methods:

Medical records of 180 consecutive IBD pts referred to the inter-disciplinary clinic were retrospectively reviewed. Data regarding age, gender, diagnosis, disease duration, clinical and laboratory features, previous and current therapy, Harvey-Brandshaw Index were entered into a database and analyzed. Beighton’s scoring of ≥4/9 was used to define patients with JHM. The 1998 Brighton’s criteria were used to identify patients with BJHS. Outcome was defined as improvement of joint pain. The statistical methods used included descriptive statistics, T test, Spearman’s correlation and multiple logistic regression analysis.

Results:

Forty-six patients (mean(SD) age 36.2(12.4), disease duration 13.9(8.8) years) out of 180 IBD patients (mean(SD) age 40.4(14.3), disease duration 15.7(9.1) years) fulfilled the criteria for JHM. Twelve patients had active inflammatory joint disease (2 with axial involvement, 10 with peripheral joint disease and 2 with axial and peripheral joint involvement). The other 32 answered both major criteria for BJHS. The median Beighton scoring was 7 (range 5-9). Most of them were on biological treatment. Patients with JHM suffered frequently of arthralgia and abdominal pain, in spite of endoscopic remission and normal levels of calprotectin and inflammatory markers (p=0.02, r=0.17). JHM and BJHS were associated with poorer outcome (p=0.004, r=0.2). In a multiple logistic regression analysis, only JHM reached borderline significance for predicting worse outcome.

Conclusion:

Joint and abdominal pain did not improve with immunomodulatory therapy in IBD patients with JHM. JHM may have a negative impact on achievement of clinical remission, in a significant subset of IBD patients. Rheumatologists and gastroenterologists should be aware of this.

Disclosure of Interests: :

Haya Zidany: None declared, Matti Waterman: None declared, Kohava Toledano: None declared, Yehuda Chowers: None declared, Doron Markovits: None declared, Amir Karban: None declared, Alexandra Balbir-Gurman Consultant of: Novartis, Yolanda Braun-Moscovici: None declared

AB1028 A SINGLE-CENTER EXPERIENCE WITH TRANSIENT OSTEOPOROSIS – PATIENT CHARACTERISTIC AND APPROACH TO THERAPY

Background:

Transient osteoporosis (TOP) or transient bone marrow edema syndrome is an enigmatic condition of unknown etiology first described in pregnant women. Though usually self limited, TOP causes pain and debilitation and predisposes the patient to avascular necrosis or fractures. The course can be protracted and patient may suffer relapses. Diagnostic method of choice is magnetic resonance imaging (MRI). Based on small case series and expert opinion, several therapeutic approaches have been proposed to hasten the recovery, including bisphosphonates, calcitonin, teriparatide. However, the literature is scarce and additional experience is needed to promote the understanding of this condition.

Objectives:

To present our experience with TOP, including patient’s characteristic, approach to diagnosis, prognosis and therapy

Methods:

It is retrospective, single center study, conducted in Rambam healthcare campus, Haifa, Israel. All the medical files of patients referred to Rheumatology unit between years 2010-2020 were screened for diagnosis of TOP. Search words included: “osteoporosis”, “bone marrow edema”, “transient osteoporosis”. The files were reviewed for patient’s characteristics, modality of diagnosis, duration until full recovery, treatments and relapses.

Results:

Eight patients with at least one episode of TOP were identified using the search words. Six patients (75%) were female. Three female patients developed TOP during or shortly after pregnancy. Two patients – one male and one non pregnant female suffered from TOP after bariatric surgery. One pregnant woman had a strong family history of TOP. The most frequent involved site in order of frequency were: hip (4/8), ankle (3/8) and knee (2/8). Six patients presented with more than one simultaneous site of TOP (hips, knees and ankles). Blood count, liver and Kidney function tests, markers of bone resorption, rheumatoid factor, Anti cyclic citrullinated peptide, Antinuclear antibodies were negative in all of the patients. C-reactive protein was elevated in 4/8 patients, Erythrocyte sedimentation rate was elevated in 2/8 patients. All patients had vitamin D deficiency. The diagnosis was confirmed by MRI. All the patients were treated with vitamin D and intra-venous Pamidronate, one patient with addition of calcitonin and one patient with addition of intra venous Iloprost. Time to recovery ranged from 1.2 to 6 months. The time to recovery was the same in pregnancy related TOP. Recovery was confirmed with follow-up MRI in all the patients. Relapses occurred in 4/8 patients and only one them had pregnancy related TOP. All the patients were treated by multidisciplinary team, including orthopedic surgeon, physiotherapist and psychologist when needed.

Conclusion:

Our experience with TOP was enriched in patients presenting with more than one site of disease probably representing referral bias. Pregnancy related TOP was associated with lower risk of relapse. In terms of time to recovery there was no trend between pregnancy related and non related TOP or one site versus several sited TOP. None of the patients developed fracture, advocating in favor of adding bisphosphonates to therapy. Multidisciplinary approach is an essential part of TOP treatment strategy.

Disclosure of Interests:

Sami Giryes: None declared, Katya Dolnikov: None declared, Alexandra Balbir-Gurman Consultant of: Novartis, Daniela Militianu: None declared, Natalia Puchkov: None declared, Yolanda Braun-Moscovici: None declared

Pneumatosis cystoides intestinalis in scleroderma-related conditions

AIMS

Pneumatosis cystoides intestinalis (PCI) is a rare life-threatening gastrointestinal complication in the course of connective tissue disease (CTD). PCI is characterised by the appearance of intramural clusters of gas in the small and large bowel wall on X-ray or computed tomography and often is accompanied by free air in the peritoneal cavity.

METHODS

We present three cases of PCI in patients with scleroderma-related conditions. A review of the English language literature published on MEDLINE from 1973 to 2008 was conducted using the terms: 'systemic sclerosis', 'connective tissue disease' and 'pneumatosis cystoides intestinalis'. This review focused on clinical features, diagnostic and treatment strategies of PCI in the context of CTD.

RESULTS

Symptoms of PCI are non-specific: abdominal pain, vomiting, constipation, bloating and weight loss. Coexistence of PCI with other manifestations of CTD, such as intestinal pseudo-obstruction and/or bacterial overgrowth, complicates the clinical diagnosis. Treatment approach to PCI is mostly conservative: intestinal 'rest', parenteral nutrition, antibiotics, fluids and electrolyte supplementation, and inhaled oxygen. Surgical intervention should be performed only in cases of bowel perforation, ischaemia or necrosis. Patients with PCI have high mortality rates due to PCI itself but also to the severity and variety of basic CTD complications.

CONCLUSION

Recognition of PCI, particularly in the context of underlying CTD, is necessary for proper therapeutic application. In patients with underlying CTD and symptoms of abdominal emergency, recruitment of multidisciplinary teams, including rheumatologist, gastroenterologist, imaging specialist and surgeons familiar with intestinal complications of CTD-related conditions, is warranted.

Clinical prediction of 5-year survival in systemic sclerosis: validation of a simple prognostic model in EUSTAR centres

OBJECTIVE

Systemic sclerosis (SSc) is associated with a significant reduction in life expectancy. A simple prognostic model to predict 5-year survival in SSc was developed in 1999 in 280 patients, but it has not been validated in other patients. The predictions of a prognostic model are usually less accurate in other patients, especially from other centres or countries. A study was undertaken to validate the prognostic model to predict 5-year survival in SSc in other centres throughout Europe.

METHODS

A European multicentre cohort of patients with SSc diagnosed before 2002 was established. Patients with SSc according to the preliminary American College of Rheumatology classification criteria were eligible for the study when they were followed for at least 5 years or shorter if they died. The primary outcome was 5-year survival after diagnosis of SSc. The predefined prognostic model uses the following baseline variables: age, gender, presence of urine protein, erythrocyte sedimentation rate (ESR) and carbon monoxide diffusing capacity (DLCO).

RESULTS

Data were available for 1049 patients, 119 (11%) of whom died within 5 years after diagnosis. Of the patients, 85% were female, the mean (SD) age at diagnosis was 50 (14) years and 30% were classified as having diffuse cutaneous SSc. The prognostic model with age (OR 1.03), male gender (OR 1.93), urine protein (OR 2.29), elevated ESR (1.89) and low DLCO (OR 1.94) had an area under the receiver operating characteristic curve of 0.78. Death occurred in 12 (2.2%) of 509 patients with no risk factors, 45 (13%) of 349 patients with one risk factor, 55 (33%) of 168 patients with two risk factors and 7 (30%) of 23 patients with three risk factors.

CONCLUSION

A simple prognostic model using three disease factors to predict 5-year survival at diagnosis in SSc showed reasonable performance upon validation in a European multicentre study.

Seronegative polyarthritis as severe systemic disease

BACKGROUND

Severe extra-articular disease is associated with high levels of rheumatoid factor (RF ) in patients with seropositive rheumatoid arthritis (RA ) and a poor prognosis. It is said that patients with seronegative rheumatoid arthritis have a more benign course and less destructive disease. We observed several patients with seronegative non-rheumatoid polyarthritis, with aggressive extra-articular systemic disease.

OBJECTIVES

Review of seronegative systemic polyarthritis with clinical presentation of typical cases.

METHODS

Medline search for systemic manifestations of seronegative polyarthritis.

CLINICAL PRESENTATIONS

1. A 56-year-old woman was admitted to the cardiac intensive care unit with stabbing presternal chest pain aggravated by breathing and progressive dyspnoea, which gradually developed over a period of two weeks with one episode of fever at 38.0 degrees C. She had suffered chronic pain in her buttocks for three years with polyarthralgia and evanescent palmar-plantar rash. Imaging showed bilateral sacroiliitis (HLA B27 negative) and a large pericardial effusion. Extra-articular manifestations of SAPHO syndrome were proposed and she was successfully treated with combined therapy: pulse methylprednisolone, azathioprine, colchicine and prednisone. 2. A 47-year-old woman with psoriatic arthropathy developed high fever with leucocytosis and thrombocytosis and lung infiltrates during exacerbation of her joint disease . She was treated with pulse methylprednisolone followed by corticosteroid tapering, anti-TNF (infliximab) and methotrexate with complete resolution. 3. A 19-year-old man with inflammatory bowel disease developed acute pericarditis with response to 6-mercaptopurine, salazopyrine and prednisone.

RESULTS

We discuss a range of seronegative arthritis diseases with possible systemic manifestations including the main procedures for early diagnosis. Infection, malignancy, hypersensitivity, granulomatous disease and other collagen diseases such as systemic lupus erythematosus should be excluded, but investigations for an underlying disease should not delay early corticosteroid and immunosuppressive therapy.

CONCLUSION

A high level of suspicion of extra-articular disease should always be maintained when treating active seronegative polyarthritis.

Vaccination against influenza in patients with rheumatoid arthritis: the effect of rituximab on the humoral response

OBJECTIVE

To assess the effect of rituximab on the efficacy and safety of influenza virus vaccine in patients with rheumatoid arthritis (RA).

METHODS

The study group comprised patients with RA treated with conventional disease-modifying drugs with or without rituximab. Split-virion inactivated vaccine containing 15 microg haemagglutinin/dose of B/Shanghai/361/02 (SHAN), A/New Caledonian/20/99 (NC) (H1N1) and A/California/7/04 (CAL) (H3N2) was used. Disease activity was assessed by the number of tender and swollen joints, duration of morning stiffness and evaluation of pain on the day of vaccination and 4 weeks later. CD19-positive cell levels were assessed in rituximab-treated patients. Haemagglutination inhibition (HI) antibodies were tested and response was defined as a greater than fourfold rise 4 weeks after vaccination or seroconversion in patients with a non-protective baseline level of antibodies (<1/40). Geometric mean titres (GMT) were calculated in all subjects.

RESULTS

The participants were divided into three groups: RA (n = 29, aged 64 (12) years), rituximab-treated RA (n = 14, aged 53 (15) years) and healthy controls (n = 21, aged 58 (15) years). All baseline protective levels of HI antibodies and GMT were similar. Four weeks after vaccination, there was a significant increase in GMT for NC and CAL antigens in all subjects, but not for the SHAN antigen in the rituximab group. In rituximab-treated patients, the percentage of responders was low for all three antigens tested, achieving statistical significance for the CAL antigen. Measures of disease activity remained unchanged.

CONCLUSION

Influenza virus vaccine generated a humoral response in all study patients with RA and controls. Although the response was significantly lower among rituximab-treated patients, treatment with rituximab does not preclude administration of vaccination against influenza.

Intravenous immunoglobulins in polyarteritis nodosa restricted to the limbs: case reports and review of the literature

Polyarteritis nodosa (PAN) of the calf muscles is a rare form of vasculitis. We present two cases of PAN limited to the calf and a review of the literature, based on a MEDLINE (PubMed) search of the English literature from 1980 to 2005, using the key words "vasculitis restricted to limbs", "polyarteritis nodosa", and "intravenous immunoglobulin". PAN limited to the calf muscles is a condition presenting with severe shin pain and walking difficulties. In contrast to classic PAN, there is no skin, joint, visceral or nerve system involvement in this form of the disease. The main clinical signs are tenderness and swelling of the calf. Inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein, are usually elevated, and a perinuclear pattern of anti-neutrophil cytoplasm antibodies can be found. Electromyography of the calf is not contributory. Magnetic resonance imaging may be useful in recognizing the limb-restricted vasculopathy and selecting the muscle biopsy site, which is obligatory for diagnosis. Corticosteroids (CS) are the main treatment regimen, but CS-resistant cases have been reported. The patients presented here failed to respond to CS but were successfully treated with intravenous immunoglobulin therapy (IVIG). In the absence of vital organ involvement, the addition of cytotoxic drugs is controversial. IVIG seems to be an efficient alternative therapy in PAN limited to the calf muscles especially for patients with limitations to conventional cytotoxic treatment.

Anterior sonography of glenohumeral joint in patients with inflammatory joint disease

Ultrasonography (US) was shown as an effective imaging modality in evaluating the shoulder. The shoulder joint is probably the most accessible joint for sonography in adults. However, inflammatory changes of the shoulder have received too little attention in US studies. Anterior access for US assessment of glenohumeral joint (GHJ) has not been investigated. Another problem of patients with acute synovitis of glenohumeral joint is the difficulty to perform a 90 degrees abduction for the axillary US because of severe pain and active and passive limitation. We offer the anterior access for assessment of glenohumeral joint synovitis (GHS). Sonographic evaluation (Sonosite-Titan) was carried out in 25 patients with acute GHS and 15 healthy controls. The diagnosis of GHS was made after the patients underwent physical examination and the laboratory evidence was obtained. We used the anterior position of transducer applied laterally to coracoid processus along the anterior joint cavity. The problem of anterior joint cavity investigation in neutral position is a poor presentation of the joint and the application of the biceps tendon. The problem is simply resolved after supination of the hand and external rotation of the shoulder. We measured and compared upper, middle, and lower width of the anterior GHJ cavity. Echogenicity of joint cavity was assessed by comparison with adjacent tissues. Homogeneity and regularity of GHJ cavity was designated in both groups as well. We measured labrum-infraspinatus distance on posterior view for assessment of GHJ synovitis. All cases of GHJ synovitis were confirmed by a US Doppler study. US investigation of healthy controls enabled to find normal values of the width of the anterior GHJ cavity that was less than 7.4 mm. The synovitis group showed GHJ cavity expansion: 8.3+/-2.4 (p=0.001) and 10.5+/-3.1 (p<0.001) for the middle and the lower anterior part of the GHJ respectively. The upper part width was not different in synovitis and control groups. Anterior joint cavity extension to 7.4 mm and upper in its lower part was high sensitive (96%) and specific (86%) US sign of synovitis with the test power above 0.9. The posterior labrum-infraspinatus extension had high specificity for synovitis (100%), but only seven of 25 patients (28%) had increased (>2 mm) the value of the labrum-infraspinatus dimension, which was previously proposed as the US sign of synovitis. Echogenicity of the anterior joint cavity in healthy controls was moderately high (far more echogenic than deltoid muscle). Echogenicity of synovitis declined, and mild effusions were found to be common. Those were not to be seen on US of GHJ in neutral position and were revealed only in supination and external rotation of the shoulder. Intra-articular tissue of healthy controls was relatively echo-homogenic compared with nonhomogenic one of the synovitis group. Bone irregularity was found in patients with long-standing GHJ synovitis reflecting erosive process. A certain position of the shoulder and good knowledge of the normal anterior joint cavity parameters enabled us to diagnose synovitis by anterior shoulder sonography, with the patients experiencing minimal pain during movements.

Sustained benefit in rheumatoid arthritis following one course of rituximab: improvements in physical function over 2 years

OBJECTIVES

To evaluate the long-term impact on physical function of a single course of rituximab in rheumatoid factor, seropositive patients with active rheumatoid arthritis (RA) despite ongoing methotrexate treatment.

METHODS

A randomized, controlled trial comparing rituximab alone [1,000 mg intravenously (iv) on days 1 and 15, n= 40], or in combination with cyclophosphamide (750 mg iv on days 3 and 7, n= 41) or oral methotrexate (> or =10 mg/week, n= 40) with placebo + methotrexate (> or =10 mg/week, n= 40), resulted in significant reductions in disease activity at weeks 24 and 48. Sustained improvements in physical function and standard effect sizes (SES) for changes in components of ACR and EULAR criteria were evaluated over 2 yrs.

RESULTS

More patients receiving rituximab + methotrexate completed a 2-yr follow-up without further treatment than those receiving placebo + methotrexate (45% vs 15%, respectively), rituximab alone (10%) or rituximab + cyclophosphamide (22%). This reflected a higher percentage of patients receiving rituximab + methotrexate reporting improvements in Health Assessment Questionnaire Disability Index > or = minimum clinically important difference at 1 and 2 yrs (68% and 30%, respectively) compared with placebo + methotrexate (28% and 15%), rituximab monotherapy (43% and 10%) or rituximab + cyclophosphamide (39% and 12%). SES were high in all rituximab groups and revealed differing patterns of response over time.

CONCLUSION

A single course of rituximab with continuing methotrexate in patients with active RA provided clinically meaningful improvements in physical function over 2 yrs, with lower discontinuation rates and larger SES for improvements in ACR and EULAR criteria components.

Essential mixed cryoglobulinemia type II

We report a rare case of essential mixed cryoglobulinemia type II with membrano-proliferative glomerulonephritis (MPGN) type I in which HCV was not found. Long-term history of palindromic rheumatism, skin leukocytoclastic vasculitis attacks and micro-normocytic anemia preceded the appearance of cryoglobulinemia. Cryoprecipitate consisted of monoclonal IgMk-RF and polyclonal IgG (essential mixed type II). The newly appreciated cryoglobulinemia was associated with Coombs positive hemolytic anemia. The MPGN in this case had a benign course and responded to complex simple therapies including prevention of exposure to cold, low antigen content diet, treatment of provoking factors such as UTI, and maximal dose of ACE inhibitor. Responsiveness of skin vasculitis to colchicine therapy was restored after a two-month colchicine withdrawal period and therefore corticosteroid and immunosuppressive therapy was postponed.

Serum-synovial gradient data of normouricemic patients with history of gout and acute knee effusion

The etiology of arthritis episodes in normouricemic patients with gout is still unclear. We propose that the fluctuation in synovial urate level, as well as pH, ion strength, albumin, and globulin values relative to serum levels, could be involved in crystal formation. To assess serum-synovial gradient (SSG), the sera and synovial fluid (SF) of six normouricemic patients (men, age 48-79) with a history of gout (American College of Rheumatology criteria) and acute knee effusion were screened for uric acid, pH, osmolality (Osm), P/Ca, albumin, globulin, and SSG. Monosodium urate monohydrate (MSUM) crystals were determined by polarized light (PL). Infectious arthritis was ruled out via Gram staining and synovial fluid culture. Negative X-ray and PL microscopy results excluded chondrocalcinosis. Five patients (1-5) had inflammatory knee effusion (WBC >2,000/mm(3)), and one (patient 6) had noninflammatory knee effusion (600 WBC/mm(3)). MSUM crystals were found in the WBC of patient 1 only. He had tophaceous gout with normal serum uric acid levels and showed significant negative Osm and P and positive Ca SSG. Two crystal negative patients had severe negative pH SSG with alkaline synovial fluid, significant P/Ca SSG, and high positive globulin SSG, while one of them had supersaturated SF uric acid content. The other patients displayed an increased Osm and P/Ca SSG. All SSG values were five to ten times higher than the coefficient of variance for used methods. Noninflammatory SF of patient 6 does not appear to be related to active gout. The data on SSG for MSUM, pH, Osm, Alb/Glob, and P/Ca in normouricemic patients with gout history and acute knee effusion was not homogeneous. We propose that acid-base and ionic-protein gradient may lead to instability of subsaturated urate solution, thereby predisposing to MSUM deposits within synovial membrane and inducing inflammation.

Recalcitrant leg ulcer due to mixed connective tissue disease

We present a 28-year-old woman with mixed connective tissue disease (MCTD) complicated by a recalcitrant longstanding leg ulcer, which responded to complex therapy with local polydine, systemic ciprofloxacin, iloprost, enoxaparin and aspirin. Cyclophosphamide pulse therapy and corticosteroids controlled the systemic inflammation but failed to heal the leg ulcer. We considered a rationale of complex therapy for the leg ulcer on a basis of pathogenesis and complications of MCTD.

Seasonal distribution of relapse onset in rheumatoid arthritis and spondyloarthropathy: the possible effect of the solar factor

BACKGROUND AND OBJECTIVE

The seasonal effect on the relapse of rheumatoid arthritis and spondyloarthropathies is still unclear. To assess the seasonal distribution of relapse onset in rheumatoid arthritis (RA) and spondyloarthropathy (SpA) and its association with solar factors.

METHODS

The monthly distribution of relapse onsets during the years 1998-2000 was retrospectively chart reviewed in 364 patients. In 1998 a total of 131 patients were studied; 60 with seropositive (sp) RA, 30 with seronegative (sn) RA and 41 with SpA; 113 patients in 1999: 44 with spRA, 38 with snRA and 31 with SpA; 120 patients in 2000: 56 with spRA, 38 with snRA and 26 with SpA. All of them were treated in the Department of Rheumatology, which serves the population of northwestern Israel. Solar activity was analyzed according to the "Solar Terrestrial Activity Report Charts 1998-2000". The Central Israel Bureau of Statistics provided the sun global radiation data. Data was assessed during the summer (April-September) and winter (January-March, October-December). The correlation between the monthly distribution of disease relapses and solar factors was measured (SPSS-10 for WIN).

RESULTS

Relapses in spRA patients occurred mostly during the summer months with peak activity during the month of July 2000. Single monthly peaks of spRA relapse onset were noted in January 1998-1999 and April 1998 and for snRA in January 1998 and June 2000, but there were no seasonal differences for spRA, snRA and SpA in 1998-1999 and for snRA and SpA in 2000. Relapses in spRA patients were associated with a summer bias of increased solar activity and global solar radiation in 2000 compared with lower peak solar activity in 1998-1999. Furthermore, in 2000 we found a significant correlation of the spRA monthly relapse count to solar activity (p = 0.005) and global sun radiation (p = 0.048) unlike snRA and SpA. No above-mentioned association and correlation was noted in 1998-1999. We revealed mild negative correlation (p = 0.046) of SpA relapse count only to peak solar flux (PSF) by analysis of data for 1998-2000 as one united group.

CONCLUSIONS

Relapses were more frequent during the summer of 2000 (May-June-July) in spRA but not in snRA and SpA. The reasons are still unclear. No seasonal differences were observed in 1998-1999. Enhanced solar activity in summer-2000 compared with 1998-1999 may be inferred to be the proposed cause but coincidence may occur as well. Outbreak in RA and SpA was not registered despite increased peak solar activity in 2000. We observed mild evidence of reciprocal relation between SpA relapsing and solar activity during 1998-2000. Solar and any other possible contributory factors remain still to be elucidated.