Kinetics of response to iloprost evaluated by laser speckle contrast analysis in systemic sclerosis

OBJECTIVE

Iloprost (ILO) is recommended for the treatment of systemic sclerosis (SSc) microangiopathy, but there is no common consensus on its optimal dosage. The aim of this study is to evaluate the kinetics of response to ILO administered in a daily outpatient scheme in SSc subjects using laser speckle contrast analysis (LASCA).

METHOD

Adult SSc patients in stable therapy with ILO administered for 6 h for 2 consecutive days every 4 weeks were enrolled. Peripheral finger perfusion was assessed by LASCA. Each patient underwent five LASCA evaluations: before and after each day of ILO (D1pre, D1post, D2pre, and D2post) and after 4 weeks (D30).

RESULTS

Twenty-seven SSc patients (77.8% female, mean age 61.5 years) were enrolled. LASCA showed an increase in perfusion at the end of each ILO course, but on the second day (both D1pre vs D2pre and D2pre vs D2post) the increase was no longer significant in half of the fingers. Moreover, compared to D1post, at the beginning of the second ILO day most of the fingers had already shown a significant reduction in perfusion. After 1 month, there were no statistically significant differences between the perfusion values of D1pre and D30.

CONCLUSION

This LASCA study highlights the transience of the vasoactive effect of ILO, with a perfusion benefit that is completely lost after 1 month. The brevity of the perfusion effect of ILO and the use of LASCA are elements to consider in the design of future SSc trials to determine the optimal ILO dosage.

POS0860 ULTRA-HIGH FREQUENCY ULTRASOUND FOR DIGITAL ARTERIES: COMPLETING THE CHARACTERIZATION OF VASCULOPATHY IN SYSTEMIC SCLEROSIS

Background

Despite microangiopathy is the hallmark of systemic sclerosis (SSc), macrovascular involvement is arousing interest. In particular, proper palmar digital arteries (PPDA) play an important role in Raynaud’s phenomenon and can contribute to the exacerbation of vascular damage. However, PPDA full characterization is still an unmet need.

Objectives

To assess the state of PPDA in a cohort of patients with SSc using ultra-high frequency ultrasound (UHFUS), comparing the results with those obtained in healthy controls (HC) and looking for any association with SSc-specific characteristics. Correlations between UHFUS features of PPDA and microvascular bed were also investigated.

Methods

Consecutive SSc patients without active digital ulcers and HC were enrolled. Epidemiological and SSc-specific data were collected. Each subject underwent UHFUS (70 MHz) evaluation of PPDA (2 per finger, from II to V finger bilaterally), searching for occluded or not viewable vessels and measuring the thickness of the three arterial layers, as well as the systo-diastolic excursion range. Finally, microvascular bed was investigated by capillaroscopy and laser speckle contrast analysis (LASCA).

Results

Forty-six SSc patients (87% female, mean age 55.5 years, mean disease duration 8.2 years) and 15 HC matched for age and sex were enrolled. UHFUS in SSc revealed 123 (16.7%) PPDA occluded or not viewable, whereas in HC they were all patent. Considering the finger with at least one of the two PPDA occluded or not viewable as ultrasonographically pathological, 30 (65.2%) patients presented at least one pathological finger (Figure 1). All three arterial layers were significantly thicker in SSc than in HC (p<0.001 for all), as well as systo-diastolic excursion range was significantly reduced in SSc (p<0.001). On 63 fingers previously affected by digital ulcers, 73% were ultrasonographically pathological. A direct correlation emerged between disease duration and the thickness of all three arterial layers (intima p<0.001; ρ=0.527; intima-media p<0.001; ρ=0.502; intima-media-adventitia p=0.001; ρ=0.491). No significant correlations emerged between capillaroscopy or LASCA findings and UHFUS features.

Figure 1.

Representation of the number of ultrasonographically pathological fingers per patient.

Conclusion

SSc presents a vasculopathic involvement of PPDA well characterized by UHFUS, a useful diagnostic tool able to show also subclinical vascular impairment. The lack of correlations between UHFUS and capillaroscopy or LASCA reflects the existence of vasculopathic processes that are not exactly the same. Thus, UHFUS evaluation of PPDA emerges as complementary to microcirculation assessment, in order to obtain a more accurate and complete characterization of the vasculopathy in SSc.

Disclosure of Interests

None declared

POS1246 COVID-19 IN ITALIAN PATIENTS WITH RHEUMATIC AUTOIMMUNE SYSTEMIC DISEASES: RESULTS OF A NATIONWIDE SURVEY STUDY

Background:

SARS-CoV-2 infection poses a serious challenge for patients with rheumatic autoimmune systemic diseases (ASD), characterized by marked immune-system dysregulation and frequent visceral organ involvement.

Objectives:

To evaluate the impact of Covid-19 pandemic in a large series of Italian patients with ASD.

Methods:

Our multicenter telephone survey (8-week period, March-April 2020) included a large series of 2,994 patients (584 M, 2,410 F, mean age 58.9±13.4SD years) with ASD followed at 34 tertiary referral centers of 14 regions of northern, central, and southern Italian macro areas, characterized by different prevalence of SARS-CoV-2 infection. According to currently used criteria, Covid-19 was classified as definite Covid-19 (signs or symptoms of Covid-19 confirmed by positive oral/nasopharyngeal swabs at PCR testing) or highly suspected Covid-19 (signs or symptoms highly suggestive of Covid-19, but not confirmed by PCR testing due to limited availability of virological tests in that period). The results were analyzed performing the Odds Ratio by Java-Stat 2-way Contingency Table Analysis.

Results:

The main findings of the survey study revealed a significantly increased prevalence of Covid-19 in:

a.the whole series of ASD patients (definite Covid-19: 22/2994, 0.73%; p=0.0007;

definite Covid-19 plus highly suspected Covid-19: 74/2,994, 2.47%; p<0.0001) when compared to Italian general population of Covid-19 infected individuals (349/100000 = 0.34%; data from Italian Superior Institute of Health;

https://www.epicentro.iss.it/en/coronavirus/sars-cov-2-national-surveillance-system).

b.the subgroup of patients with connective tissue diseases or systemic vasculitis (n = 1,901) compared to the subgroup of inflammatory arthritis (n = 1,093), namely rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis (definite Covid-19: 19/1,901, 0.99%, vs 3/1,093, 0.27%; p=0.036; definite Covid-19 plus highly suspected Covid-19: 69/1,901, 3.6%, vs 5/1,093, 0.45%; p<0.0001)

c.the subgroup of patients with pre-existing interstitial lung involvement (n = 526) compared to those without (n = 2,468) (definite Covid-19: 10/526, 1.90%, vs 12/2,468, 0.48%; p=0.0015; definite Covid-19 plus highly suspected Covid-19: 33/526, 6.27%, vs 41/2,468, 1.66%; p<0.0001).

Of interest, the prevalence of Covid-19 did not correlate with presence/absence of different comorbidities, mainly diabetes, cardio-vascular and/or renal disorders, as well as of ongoing treatments with biological DMARDs; while patients treated with conventional DMARDs showed a significantly lower prevalence of Covid-19 compared to those without. Covid-19 was more frequently observed in the patients’ populations from northern and central compared to southern Italian macro area with lower diffusion of pandemic. Clinical manifestations of Covid-19, observed in 74 patients, were generally mild or moderate; 4/9 individuals requiring hospital admission died for severe pneumonia.

Conclusion:

The prevalence of Covid-19 observed in ASD patients during the first wave of pandemic was significantly higher than that observed in Italian general population; moreover, the actual prevalence of Covid-19 might be underestimated due to the high number of mild variants as well as the possible clinical overlapping between these two conditions. Patients with ASD should be invariably regarded as ‘frail patients’ during the pandemic course, considering the risk of worse outcome in the acute phase of Covid-19, as well as the potential long-term effects of viral infection.

The statistically significant association of Covid-19 with connective tissue diseases/systemic vasculitis, as well as with pre-existing interstitial lung involvement, suggests the presence of distinct clinico-pathological ASD subsets, characterized by markedly different patients’ vulnerability to SARS-CoV-2 infection.

Disclosure of Interests:

None declared

AB0407 CARDIOVASCULAR BURDEN IN SYSTEMIC SCLEROSIS: QRISK3 VERSUS FRAMINGHAM FOR RISK ESTIMATION

Background:

Cardiovascular (CV) diseases, namely myocardial infarction and stroke, are not among the most known and frequent complications of systemic sclerosis (SSc), but there is growing evidence that SSc patients have a higher prevalence of CV diseases than the general population [1].

Objectives:

To compare two algorithms for CV risk estimation in a cohort of patients with SSc, finding any correlation with clinical characteristics of the disease.

Methods:

SSc patients without previous myocardial infarction or stroke were enrolled. Traditional CV risk factors, SSc-specific characteristics and ongoing therapies were assessed. Framingham and QRISK3 algorithms were then used to estimate the risk of develop a CV disease over the next 10 years.

Results:

Fifty-six SSc patients were enrolled. Framingham reported a median risk score of 9.6% (IQR 8.5), classifying 24 (42.9%) subjects at high risk, with a two-fold increase of the mean relative risk in comparison to general population. QRISK3 showed a median risk score of 15.8% (IQR 19.4), with 36 (64.3%) patients considered at high-risk. Both algorithms revealed a significant role of some traditional risk factors and a noteworthy potential protective role of endothelin receptor antagonists (p=0.003). QRISK3 was also significantly influenced by some SSc-specific characteristics, as limited cutaneous subset (p=0.01), interstitial lung disease (p=0.04) and non-ischemic heart involvement (p=0.03), with the first two that maintain statistically significance in the multivariate analysis (p=0.02 for both).

Conclusion:

QRISK3 classifies more SSc patients at high-risk to develop CV diseases than Framingham, and it seems to be influenced by some SSc-specific characteristics. If its predictive accuracy were prospectively verified, the use of QRISK3 as a tool in the early detection of SSc patients at high CV risk should be recommended.

References:

[1]Ngian GS, Sahhar J, Proudman SM, Stevens W, Wicks IP, Van Doornum S. Prevalence of coronary heart disease and cardiovascular risk factors in a national cross-sectional cohort study of systemic sclerosis. Ann Rheum Dis. 2012;71:1980-3.

Disclosure of Interests:

None declared

Prostanoids in scleroderma microangiopathy: clinical and pharmacoeconomic comparison between two intravenous regimens

Objectives: Intravenous iloprost (ILO) has widely demonstrated its effectiveness and safety in systemic sclerosis (SSc) patients. Unfortunately, there is no clear consent about dosage, duration, frequency, and infusion modality. The aim of this study was to compare two different therapeutic schemes in the same cohort of consecutive SSc subjects, evaluating differences in terms of effectiveness [digital ulcer (DU) outcome], safety, and direct healthcare costs.Method: This was a retrospective observational study of 47 patients classified with SSc treated with intravenous ILO for severe Raynaud's phenomenon and/or DUs. Two regimens were compared: a continuous inpatient scheme and a daily outpatient scheme. Demographics and clinical data, concomitant therapies, adverse events, and data on resource use and costs were collected.Results: The number of DUs rose slightly with the switch from the continuous to the daily scheme (0.61 ± 1.2 vs 1.1 ± 1.7). Moreover, in the daily scheme there was an increase in the number of therapeutic cycles (2.4 ± 0.7 vs 4.71 ± 1.4, p < 0.001) and an increase in patients treated with other vasoactive drugs. There was a reduction in ILO tolerability and more than half of the patients suspended the treatment. Five patients required hospitalization for severe and refractory DUs in the daily scheme. Moreover, the costs of the two treatments were comparable [median 7174 (range 2748-18 524) EUR vs 6284 (3232-22 706) EUR, p = 0.712].Conclusion: Treatment with a daily scheme of ILO is characterized by worse tolerability and a higher dropout rate compared to a low-flow regimen, with similar costs. We suggest that a low-flow continuous therapeutic scheme is preferable in SSc patients.

SAT0311 BIOELECTRICAL IMPEDANCE VECTOR ANALYSIS FOR NUTRITIONAL STATUS ASSESSMENT IN SYSTEMIC SCLEROSIS AND ASSOCIATION WITH DISEASE CHARACTERISTICS

Background:

Bioelectrical impedance vector analysis (BIVA) is a common non-invasive method for estimating body composition which ultimately allows to obtain information on subject’s nutritional status. So far no data about the use of BIVA in patients with systemic sclerosis (SSc) have been published.

Objectives:

We used BIVA in a cohort of SSc patients in order to assess their nutritional status and any correlation with the various clinical characteristics of the disease, also evaluating the differences with the general population.

Methods:

We collected data from consecutive patients diagnosed with SSc according to EULAR/ACR criteria and from healthy controls (HC) matched for age and sex. Patients underwent BIVA for the assessment of fat mass (FM), free fat mass (FFM), total body water (TBW), extracellular water (ECW), body cellular mass (BCM), basal metabolic rate (BMR) and ECM/BCM ratio, an early index of protein catabolism. Data included anthropometric and clinical features, Body Mass Index (BMI) and specific organ involvement with particular attention to gastrointestinal symptoms. Laboratory parameters, including haemoglobin and albumin levels, were also collected. Additionally, patients completed the UCLA GIT 2.0 questionnaire.

Results:

Data from 50 SSc patients (92% female; mean age 61.1±12.5 years; mean disease duration 13.4±10.2 years) and from 50 HC were compared. BIVA revealed that SSc patients presented a significant reduction in BMR, BCM and ECW values compared to HC (p<0.001 for all). The former also exhibited a higher ECM/BCM ratio (p<0.001). No significant differences regarding FM, FFM, TBW and BMI were found between the two groups. Among the cohort of SSc patients, a direct correlation was found between age and ECW (p=0.001; ρ=0.473) and between disease duration and FM (p=0.023; ρ=0.325), whereas age inversely correlated with BMR (p=0.012; ρ=-0.357). Patients with anaemia and/or hypoalbuminemia had significantly reduced BMR, BCM and TBW values; those with hypoalbuminemia also had elevated ECW levels (p=0.001). No other significant associations with BIVA values were found among the laboratory findings and among the gastrointestinal complaints. Results showed relevant interrelations between BIVA parameters and the SSc-related involvement of different organs, e.g. digital ulcers, interstitial lung disease and pulmonary arterial hypertension (See Table 1). In addition, a higher skin involvement inversely correlated with FM (p=0.038; ρ=-0.387). The only correlation that emerged from the UCLA GIT 2.0 questionnaire was the inverse relationship between TBW and GIT-reflux (p=0.017; ρ=-0.385). Four patients died during the study: they had significantly lower BMR and BCM, with an increased ECW.

Table 1.Ongoing digital ulcersHistory of digital ulcersInterstitial lung diseasePulmonary arterial hypertensionHeart involvementFMp=0.006nsp=0.042nsnsFFMp=0.019p=0.046nsnsnsTBWp<0,001nsp=0.007nsnsECWnsnsp=0.015p=0.004p=0.02BCMp=0.01p=0.047p=0.016p=0.013p=0.03BMRp=0.002p=0.036p=0.004p=0.015nsECM/BCMnsnsp=0.034nsns

Conclusion:

BIVA has shown that SSc patients have a worse nutritional status than HC. The parameters obtained with BIVA in SSc patients correlate with serological malnutrition markers (haemoglobin and albumin), with various organ-specific SSc manifestations (cardiopulmonary involvement and digital ulcers) and with mortality. BIVA could therefore play a role in the prognostic stratification of SSc patients.

Disclosure of Interests:

None declared

THU0339 THE INFLUENCE OF SKIN CALCINOSIS ON THE PROGNOSIS OF DIGITAL ULCERS IN PATIENTS WITH SSC

Background:

Digital ulcers (DUs) are one of the main burdens in patients with systemic sclerosis (SSc) as they have a major impact on quality of life and prognosis. Some DUs are associated with the presence of subcutaneous calcinosis (SC) that may worsen their management, and the prognosis of these DUs is still not well defined.

Objectives:

To define the characteristics of SSc patients with DUs related to SC and analyze the impact on prognosis and on healing time.

Methods:

We prospectively collected data from DUs of the hands evaluated in our dedicated wound-care outpatient clinic from October 2018 to August 2019. Fifty-five patients were enrolled (50 females, 18 with limited-SSc and 37 with diffuse-SSc, mean age 62.3±17.2 years). For every DU we collected: presence/absence of calcinosis, pathogenesis (spontaneous, post-traumatic), area of DU, location (fingertip, periungual area, metacarpophalangeal, proximal/distal interphalangeal-PIP/DIP), VAS-pain at the baseline and after two weeks, local signs of infection (edema, redness), deep wound swab results and time to the healing. Additionally, we calculated the wound-bed score (WBS), at the baseline and we correlated the total score with the time of healing. All the ulcers were managed with weekly treatment following a definite protocol: wound cleansing, disinfection, mechanic debridement, application of antiseptic dressing.

Results:

Out of 98 DUs evaluated, 24 (24.5%) were associated with SC. Patients with SC were older than those without calcinosis (67.1+-16.9 vs 59.4+-16.9 p<0.05) and were more frequently affected by lc-SSc (18 – 75% vs 6 – 25% p<0.001). There were no significant differences between the mean areas of DUs (SC 22mm2vs non-calcinosis 30.8mm2) neither in the localization of the ulcers: fingertip (14-61% vs 34-49.3%), periungual area (4-17.4% vs 16-23.2%), PIP (2-9% vs 13-18.9%), DIP (2-9% vs 9-13%) and MCP (1-4% vs 4-5.8%). The VAS-pain was not statistically different at the baseline (6.0 for SC vs 5.4), neither after 2 weeks (3.8 vs 3.2). Although the presence of local signs of infection was similar (5-20.8% vs 14-18.9%), the positivity for the wound swab was higher in SC compared with those without calcinosis (6-26.1% vs 9-11.5%; p=0.05).

All the DUs treated in our outpatient clinic healed but those with SC required more weeks (10.4±7.9 vs. 7.13±5.7; p=0.03). The WBS was similar in the two groups (8.96+-0.46 in SC vs 9.43+-0.33) and was negatively correlated with the time of healing (r=-0.24, p=0.02).

Conclusion:

Although DUs with calcinosis have a different pathogenesis compared to those without SC, the location, dimensions and DU-related pain are similar in both groups. Despite these aspects, DUs associated with calcinosis are more prone to be infected and require more time to heal; the WBS may represent a simple, easy-calculated score to predict the time for DUs healing. The presence of calcinosis may represent a negative prognostic factor in the management of SSc-DUs.

References:

[1]Falanga V, Saap LJ, Ozonoff A. Wound bed score and its correlation with healing of chronic wound. Dermatol ther, 2006 Nov-Dec;19(69):383-90

Disclosure of Interests:

None declared

Translation, cultural adaptation and validation of the Systemic Lupus Erythematosus Activity Questionnaire (SLAQ) in a cohort of Italian systemic lupus erythematosus patients

Introduction The Systemic Lupus Erythematosus Activity Questionnaire (SLAQ) is a patient-reported instrument for the assessment of disease activity in systemic lupus erythematosus (SLE). The aims of the present study are translation, cultural adaptation and validation of an Italian version: the SLAQit. Methods The process of translation and cultural adaptation followed published guidelines. SLAQit was pretested in a group of 35 SLE patients to evaluate acceptability, comprehension and feasibility. Internal consistency, test-retest validity and external validity were tested on consecutive SLE patients attending the clinic. Results In total, 135 SLE patients were enrolled in this study. The pilot test provided a 99.9% response rate and demonstrated feasibility and comprehensibility of the questionnaire. A good internal consistency was found among the three components of the score (SLAQ score, numerical rating scale (NRS), patient global assessment question (PGA); α = 0.79). SLAQit showed very high reliability (test-retest α > 0.8). NRS and PGA showed a strong positive correlation with both Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) ( p = 0.002 and p < 0.001, respectively) and European Consensus Lupus Measurement (ECLAM) scores ( p = 0.01 and p < 0.001, respectively), while the SLAQ score did not. A significant agreement was observed between the physician's intention to treat and both the NRS and PGA scores, while no significant association was reported with the SLAQ score. Conclusions SLAQit was demonstrated to be a reliable and valid instrument for self-assessment of disease activity in SLE patients.

Post-occlusive reactive hyperaemia (POHR) in systemic sclerosis: very early disease (VEDOSS) represents a separate entity compared to established disease

OBJECTIVES

Vascular involvement is a key feature of systemic sclerosis (SSc). Vascular changes are central to the pathogenesis of the disease and the assessment of vascular involvement has a prognostic value. This assessment therefore has a pivotal role in the management of SSc patients. The aim of our study was to evaluate post-occlusive reactive hyperaemia (PORH) in consecutive SSc patients and to test whether a PORH test might be a useful tool for the early diagnosis of SSc.

METHOD

Between April 2011 and April 2015, 60 consecutive SSc patients (mean age 56 ± 15 years, females:males = 18:1) were enrolled in the study. The patients were divided into those with full-blown SSc (n = 50) and those with very early diagnosis of SSc (VEDOSS) (n = 10) according to the literature. Laser speckle contrast analysis (LASCA) was used to assess PORH.

RESULTS

A statistically significant difference was detected in the post-ischaemic hyperaemic peak flow between VEDOSS and established SSc (424% vs. 137%, p = 0.0011). PORH peak flow decreased according to the capillaroscopic pattern (early = 419%, active = 163%, late = 145%, p = 0.0027). Moreover, a correlation between capillary density and peak flow was revealed (rho = 0.33, p < 0.01).

CONCLUSIONS

These data show a different pattern of vascular involvement in VEDOSS compared to established disease that mirrors capillaroscopic changes. Functional features of very early and established disease seem to be the physiological counterpart of abnormalities detected by capillaroscopy. The POHR test might be a useful aid for further characterization of vascular involvement in SSc. In particular, blunted POHR might prove a tool to separate pre-clinical from full-blown SSc.

Systemic vasculitides: a critical digest of the most recent literature

Herewith we provide our annual digest of the recent literature on systemic vasculitides. In this manuscript, we reviewed all the articles published during the last 12 months on large-, medium- and small-vessel vasculitis and selected the most relevant studies regarding the epidemiology, pathogenesis and management of systemic vasculitis. In particular, we focused the attention on giant cell arteritis, ANCA-associated vasculitis and cryoglobulinaemia.

Systemic sclerosis: a critical digest of the recent literature

Systemic sclerosis is a complex disease characterised by chronic multisystem involvement of internal organs; every year many studies are published on the diagnosis, pathogenesis and treatment of the disease. In this article, we provide a critical analysis of the recent literature on systemic sclerosis, with particular focus on the most relevant studies published over the last two years.

Analysis of the prevalence of cataracts and glaucoma in systemic lupus erythematosus and evaluation of the rheumatologists' practice for the monitoring of glucocorticoid eye toxicity

Chronic glucocorticoid (GC) therapy is associated with an increased risk of developing cataracts and glaucoma, and recommendations have been developed for monitoring these side effects in patients with rheumatic diseases. The aim of this study was to assess the prevalence of cataracts and glaucoma and the adherence to the existing recommendations for monitoring eye toxicity of chronic GC therapy among systemic lupus erythematosus (SLE) patients in routine clinical practice. Clinical charts of 170 patients were examined, and 34 (20%) of them never underwent an eye assessment. The remaining 136 underwent an eye assessment with an interval of 75 ± 61.7 months. Only 45 (33%) had received an evaluation during the previous 12 months. All these 170 patients were taking chronic CG therapy at a mean daily dose of 5.4 ± 2.4 mg prednisone and a mean cumulative dose of 27.6 ± 20.5 g. Out of the 136 patients with at least one eye assessment, cataracts were observed in 39 patients (29%) and glaucoma in 4 patients (3%). Cataracts were diagnosed at a mean age of 46.5 ± 10 years; the development of cataracts was associated with age, disease duration, and cumulative GC dose. Glaucoma was diagnosed at a mean age of 40.5 ± 16 years; due to the small number of patients, no correlations were made. The prevalence of cataracts and glaucoma is higher than in the general population, and these conditions occur early in the life of SLE patients. An association between GC and cataracts is confirmed. The adherence to recommendations is suboptimal as only 33% of patients underwent an eye assessment over the previous 12 months. These data reinforce the need to improve adherence to recommendations for eye monitoring among SLE patients under chronic therapy with GC.

Systemic vasculitis: a critical digest of the recent literature

Herewith we provide a critical digest of the recent literature on systemic vasculitis. In this manuscript, we reviewed all the articles published during the last 12 months on large-, medium- and small-vessel vasculitis and selected the most relevant studies regarding the epidemiology, pathogenesis and management of systemic vasculitis. In particular we focused the attention on giant cell arteritis, ANCA-associated vasculitis and cryoglobulinemia.

Rhupus syndrome: assessment of its prevalence and its clinical and instrumental characteristics in a prospective cohort of 103 SLE patients

The term "rhupus" is traditionally used to describe patients with coexistence of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). The aim of the present work was to investigate prevalence, clinical and radiological picture as well as the serological profile of a series of rhupus patients; SLE patients and RA patients from our Unit were used as disease control groups. A total of 103 consecutive SLE patients were screened; among the entire cohort, 10 patients (9.7%) were classified as "rhupus". In our rhupus patients SLE features preceded the onset of arthritis in 5 patients (50%) while in the remaining patients arthritis appeared before or simultaneously (3 and 2 patients respectively). As compared with SLE patients, rhupus patients have significantly less kidney involvement (p=0.01) while no differences were observed between neuropsychiatric, cutaneous, hematological involvement or serositis. At our physical examination, 9 (90%) rhupus patients were presenting active joint involvement; CRP positivity and ESR levels resulted significantly higher than in SLE (p=0.006) patients while no differences were observed with respect to RA patients. In all rhupus patients, at least one pathological finding was revealed by ultrasound (US) examination at wrist and/or hand joints; overall, rhupus patients presented higher scores in all the US parameters with respect to SLE patients, especially at hands; no statistically significant differences have been observed with respect to RA patients. Magnetic resonance (MR) revealed erosions in all rhupus patients with a concomitant bone edema in five patients. The cumulative erosive burden in rhupus patients was significantly higher than in SLE patients and similar to RA patients (SLE vs rhupus p=0.005); bone pathology distribution was also similar between rhupus patients and RA patients. These data suggest the importance of assessing joint involvement in SLE with advanced imaging techniques and of evaluating the presence of prognostic factors for joint disease severity in order to establish adequate disease monitoring and to institute early appropriate therapies to avoid late consequences of unrecognized concomitant rheumatoid arthritis (Amezcua-Guerra et al., 2006 [25]; Zhao et al., 2009 [26]).

[Churg-Strauss syndrome: outcome and long-term follow-up of 38 patients from a single Italian centre]

OBJECTIVE

This study was aimed at verifying any potential correlation between anti-myeloperoxidase antineutrophil cytoplasmic antibodies (ANCA-MPO) and clinical features and outcome indices in Churg-Strauss Syndrome (CSS).

METHODS

Thirty-eight Churg-Strauss syndrome patients were selected from the medical records of all vasculitis patients attending the Rheumatology and Immunology Unit at the Department of Internal Medicine of the University of Pisa in the decades between 1989 and 2008. Data were analysed retrospectively. Statistical analyses of the results were carried out using the Mann-Whitney test to determine the correlations between the clinical and serological parameters. Qualitative variables were compared using contingency table analysis and Fisher's exact test.

RESULTS

ANCA-MPO were detected in15/38 (39%) patients. Positive ANCA status was associated with peripheral neuropathy (p=0.0006), whereas negative ANCA status was associated with lung involvement (p=0.002). Relapses were strongly associated with positive ANCA status (p=0.01) and with an increase in- or a reappearance of ANCA-MPO levels (p=0.006). Finally, ANCA-MPO were significantly associated with neurological damage (p=0.003).

CONCLUSIONS

The presence or absence of ANCA-MPO identify different clinical subsets in CSS. Overall, ANCA-MPO appears as a useful tool in the monitoring of CSS and in particular a good predictor of CSS relapses.

[Ultrasound lung comets: new echographic sign of lung interstitial fibrosis in systemic sclerosis]

OBJECTIVE

Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are common complications of systemic sclerosis (SSc). Echocardiography evaluates PAH, and chest sonography detects even mild ILC as ultrasound lung comets (ULC), i.e. multiple comet-tails fanning out from the lung surface and originating from subpleural interlobular septa thickened by fibrosis.

AIM

to assess ILaD and PAH by integrated cardiac and chest ultrasound in SSc.

METHODS

We enrolled 30 consecutive SSc patients (age= 54+/-13 years, 23 females) in the Rheumatology Clinic of Pisa University. In all, we assessed systolic pulmonary arterial pressure (SPAP), from maximal velocity of tricuspid regurgitation flow, and ULC score with chest sonography (summing the number of ULC from each scanning space of anterior and posterior right and left chest, from second to fifth intercostal space). All patients underwent plasma assay for anti-topoisomerase antibodies (anti-Scl70), and antiicentromere associated with development of pulmonary involvement. Twenty-eight patients also underwent high resolution computed tomography, HRCT (from 0= no fibrosis to 3= honey combing).

RESULTS

ULC number - but not SPAP - was correlated to HRCT fibrosis and presence Scl-70 antibodies. ULC number was similar in localized or diffuse forms (16+/-20 vs 21+/-19, p=ns) and was unrelated to SPAP (r=0.216, p=ns).

CONCLUSIONS

Chest sonography assessment and ULC allow a complete, simple, radiation-free characterization of interstitial lung involvement in SSc - all in one setting and with the same instrument, same transducer and the same sonographer. In particular, ULC number is associated with HRCT evidence of lung fibrosis and presence of Scl-70 antibodies.

[Analysis of the evolution to defined connective tissue diseases of patients with "early unidifferentiated connective tissue diseases (UCTD)"]

The term undifferentiated connective tissue diseases (UCTD) is used to identify systemic autoimmune diseases not fulfilling classificative criteria for defined connective tissue diseases (CTD). Aim of the present study was to evaluate the evolution to defined CTD of an historical cohort of 91 UCTD patients followed at our Unit and to describe clinical and serological characteristics of stable UCTD patients with a disease duration of more than 5 years. Patients, previously described, were selected for having an undifferentiated profile after 1 year of follow up. These patients have been regularly followed at our Unit and their diagnosis has been reassessed annually based on the existing classificative criteria. Seven UCTD patients with a follow up of less than 5 years have been excluded from the study, therefore 84 patients (F: 81, M: 3) have been analysed. During the follow up 28 patients (33%) developed a defined CTD. In particular 22 patients developed systemic lupus erythematosus (SLE), while the remaining 6 patients developed other CTDs (2 primary Sjögren's syndrome, 2 overlap syndromes, 1 Systemic Sclerosis, 1 rheumatoid arthritis). The evolution to a defined CTD occurred after a mean disease duration of 80.6+/- 66.8 months (min 14, max 336, median 72); the evolution to SLE occurred after a mean disease duration of 66.8+/-43.3 months (min 17, max 216, median 57). Anti-cardiolipin antibodies were the only variable correlated with the evolution to SLE (p<0.05). Stable UCTD were characterized by a simplified clinical picture with no major organ involvement and by a simplified autoantibody profile (anti-Ro/SSA antibodies and anti-RNP antibodies were the single antibody specificities observed in 22% and 13% of patients respectively). These results confirm previous data showing that about 30% of UCTD patients will develop a defined CTD, the predictive role of anti-cardiolipin antibodies for the evolution to SLE, and the existence of stable UCTD, distinct clinical entities with a simplified clinico-serological profile. The early identification of stable UCTD is very important both from a clinical and a research point of view. Future research is needed to define a new set of classification criteria.

How HCV has changed the approach to mixed cryoglobulinemia

Mixed cryoglobulinemia is a systemic disease due to a small vessel immune-complex mediated vasculitis. The discovery of a viral origin of the disease has launched a great expectancy among researchers and the years after this finding have been characterized by the effort to reach viral eradication in the hope of obtaining disease remission. Moreover, the use of immunosuppressives has been discouraged for many years as they could favour viral replication, and HCV infection has represented a contraindication to the more recent biological drugs directed against cytokines. The trials with antiviral agents in this disorder, however, has not met the expectations, especially when challenged with some of the most severe complications of the disease; moreover, these medications were not devoid of unexpected side effects, such as the occurrence of peripheral neuropathies. Since lymphoproliferation is one of the features of the disease, this has focused the attention of investigators on the potential benefit of newly targeted therapies specifically directed against B-lymphocytes (such as rituximab). Preliminary results on the use of these medications are promising. Furthermore, the use of biological agents in small open trials in HCV positive arthritis patients has demonstrated an acceptable safety profile. All these empirical observations should probably induce the scientific community to reconsider the therapeutical approach to HCV-related mixed cryoglobulinemia. Indeed, the use of aggressive chemotherapy treatments in the era preceding HCV discovery has not been associated with significant liver toxicities and standard chemotherapy during HCV-related lymphoma carried out a unexpected low rate of severe liver damage. Future efforts should probably focus on the potential benefit of a multi-step, combined anti-viral and cytotoxic therapy (both with standard regimens and new medications).

[Churg-Strauss vasculitis and idiopathic hypereosinophyl syndrome: role of molecular biology in the differential diagnosis of hypereosinophyl syndrome]

OBJECTIVE

Hypereosinophilic syndromes are a heterogeneous group of uncommon disorders characterized by the presence of marked peripheral blood eosinophilia, tissue eosinophilia, or both, resulting in a wide variety of clinical manifestations, often without an identifiable cause. Churg-Strauss syndrome is a systemic vasculitis characterized by prominent peripheral eosinophilia, asthma and systemic involvement. The presence of mild to severe eosinophilia and systemic involvement raise the search of many trigger factor that need to be ruled out. Distinguishing CSS from idiopathic hypereosinophilic syndrome may be particularly challenging, especially in ANCA negative patients.

METHODS

The aim of the present study was to present a small case series of patients referred to a Rheumatology Unit for mild to severe eosinophilia and signs and symptoms of systemic involvement and to outline the clinical significance of molecular biology in the work-up of hypereosinophilia.

RESULTS

Eleven patients with moderate to severe peripheral eosinophylia, were referred to our Unit from 1996 to 2007. Female to male ratio was 7/4, mean age 40.54 (range 22-75). Three out of eleven patients resulted positive for molecular biology. The diagnosis of idiopathic hypereosinophylia was confirmed in one out of three on the basis of the clinical picture and bone marrow biopsy.

CONCLUSIONS

Molecular biology may be useful in the screening and in the follow-up of a new hypereosinophylic patient.

Mixed cryoglobulinemia and mortality: a review of the literature

Mixed cryoglobulinemia is a highly heterogeneous clinical syndrome in terms of clinical presentation, extent and severity of organ involvement, immunological abnormalities and clinical course. Modern management began with the discovery of the close association between this syndrome and hepatitis C virus (HCV) infection. In this review we examined previously published studies on mortality in different series of patients with mixed cryoglobulinemia (MC). Patients with mixed cryo-globulinemia have higher mortality rates, predicted by age, renal involvement, intestinal vasculitis, widespread vasculitis and type of cryoglobulins.

Assessment of disease severity and prognosis

The Subcommittee members initially agreed on the concepts of disease activity, damage and severity, defining severity as the total effect of disease on organ function. It was decided to start with the assessment of severity using the Medsger's severity scale. A revised version of this scale was constructed. The rationale for the exclusion of other variables was provided.

European Scleroderma Study Group to define disease activity criteria for systemic sclerosis. III. Assessment of the construct validity of the preliminary activity criteria

OBJECTIVE

To further assess the construct validity of the three European Scleroderma Study Group (EScSG) preliminary activity indices for systemic sclerosis (SSc): for SSc as a whole, for diffuse SSc (dcSSc), and for limited SSc (lcSSc).

METHODS

30/290 SSc clinical charts collected for the EScSG study used to develop activity criteria for SSc were selected and sent to four clinical experts in SSc. The experts ranked the charts from 1 to 30 (1=lowest activity, 30=highest activity). The relationships among the ranks given by each investigator and each of the three scores, and between any two of the ranks were investigated.

RESULTS

A consistently significant correlation (r(s)=0.530-0.712) was found between the ranks given by each of the four investigators and the index for the entire patient group. A similar level of agreement was detected between each couple of the four experts (r(s)=0.428-0.720). Moreover, the ranks given in patients with an index >3 were significantly higher than those given for patients with an index < or =3. This cut off point had previously been shown to best discriminate patients with active disease.

CONCLUSIONS

Of the originally developed activity indexes, the whole series index has been externally validated. The index comprises the first preliminary, but necessary, groundwork to improve the concept of disease activity in SSc, which is still ill defined. It can be used as a preliminary activity index in clinical investigational studies.

Churg-Strauss syndrome: clinical and serological features of 19 patients from a single Italian centre

OBJECTIVE

Churg-Strauss syndrome is a rare multisystem vasculitis of unknown aetiology. Due to the rarity of the disease, few single-centre case series have been described. The aim of this study was to evaluate a small series from a single Italian centre in order to describe the clinical features of the disease, the treatment and long-term follow-up.

METHODS

Nineteen Churg-Strauss syndrome patients were selected from the medical records of all vasculitis patients attending the Immunology Unit at the Department of Internal Medicine of the University of Pisa in the decade between 1989 and 2000. Data were obtained retrospectively.

RESULTS

All the patients had asthma and hypereosinophilia. As in other case series, the lungs, skin and peripheral nervous system were the most commonly involved organs. The majority of our patient received i.v. pulses of methylprednisolone followed by i.v. pulses of cyclophosphamide. The outcome and long-term follow-up were good. There were no fatalities observed in this series during the follow-up period.

CONCLUSIONS

Churg-Strauss syndrome is a systemic vasculitis occurring in patients with a history of asthma and allergic rhinitis. The positive results of the treatment protocol used in this preliminary study deserve to be tested in controlled multicentre studies.

European multicentre study to define disease activity criteria for systemic sclerosis. II. Identification of disease activity variables and development of preliminary activity indexes

OBJECTIVE

To develop criteria for disease activity in systemic sclerosis (SSc) that are valid, reliable, and easy to use.

METHODS

Investigators from 19 European centres completed a standardised clinical chart for a consecutive number of patients with SSc. Three protocol management members blindly evaluated each chart and assigned a disease activity score on a semiquantitative scale of 0-10. Two of them, in addition, gave a blinded, qualitative evaluation of disease activity ("inactive to moderately active" or "active to very active" disease). Both these evaluations were found to be reliable. A final disease activity score and qualitative evaluation of disease activity were arrived at by consensus for each patient; the former represented the gold standard for subsequent analyses. The correlations between individual items in the chart and this gold standard were then analysed.

RESULTS

A total of 290 patients with SSc (117 with diffuse SSc (dSSc) and 173 with limited SSc (lSSc)) were enrolled in the study. The items (including Delta-factors-that is, worsening according to the patient report) that were found to correlate with the gold standard on multiple regression were used to construct three separate 10-point indices of disease activity: (a) Delta-cardiopulmonary (4.0), Delta-skin (3.0), Delta-vascular (2.0), and Delta-articular/muscular (1.0) for patients with dSSc; (b) Delta-skin (2.5), erythrocyte sedimentation rate (ESR) >30 mm/1st h (2.5), Delta-cardiopulmonary (1.5), Delta-vascular (1.0), arthritis (1.0), hypocomplementaemia (1.0), and scleredema (0.5) for lSSc; (c) Delta-cardiopulmonary (2.0), Delta-skin (2.0), ESR >30 mm/1st h (1.5), total skin score >20 (1.0), hypocomplementaemia (1.0), scleredema (0.5), digital necrosis (0.5), Delta-vascular (0.5), arthritis (0.5), TLCO <80% (0.5) for all patients with SSc. The three indexes were validated by the jackknife technique. Finally, receiver operating characteristic curves were constructed in order to define the value of the index with the best discriminant capacity for "active to very active" patients.

CONCLUSIONS

Three feasible, reliable, and valid preliminary indices to define disease activity in SSc were constructed.

European multicentre study to define disease activity criteria for systemic sclerosis. I. Clinical and epidemiological features of 290 patients from 19 centres

OBJECTIVE

To investigate the existence of differences among European referral centres for systemic sclerosis (SSc) in the pattern of attendance and referral and in the clinical and therapeutical approaches.

METHODS

In 1995 the European Scleroderma Study Group initiated a multicentre prospective one year study whose aim was to define the disease activity criteria in SSc. During the study period each participating European centre was asked to enroll consecutive patients satisfying American College of Rheumatology criteria for SSc and to fill out for each of them a standardised clinical chart. Patients from various centres were compared and differences in epidemiological, clinical, and therapeutical aspects were analysed.

RESULTS

Nineteen different medical research centres consecutively recruited 290 patients. The patients could be divided into two subgroups: 173 with the limited (lSSc) and 117 with the diffuse (dSSc) form of the disease. The clinical and serological findings for the series of 290 patients seemed to be similar to data previously reported. However, when the data were analysed to elicit any differences between the participating centres, a high degree of variability emerged, in both epidemiological and clinical features and in the diagnostic and therapeutic approaches to the disease.

CONCLUSIONS

The clinical approach to SSc, not only in different countries but also in different centres within the same country, is not yet standardised. To overcome this problem, it will be necessary for the scientific community to draw up a standardised procedure for the management of patients with SSc. This would provide a common research tool for different centres engaged in research on this complex disease.

Mixed cryoglobulinemia and hepatitis C virus association: ten years later

Mixed cryoglobulinemia is a systemic vasculitis described as a triad characterized by purpura, weakness and arthralgias. Since the first description of the disease in 1964 by Meltzer and Franklin our understanding of its pathogenesis has increased considerably. The striking association of the disease with hepatitis C virus infection was initially noted in 1990. Since then, the disease has gained growing attention among investigators involved in the study of autoimmune systemic disorders because it represents one of the most intriguing models of autoimmunity triggered by a virus. Nonetheless, a number of answered questions still remain to be resolved and are reviewed in this article.

HBV and HCV infection, polyarteritis nodosa and mixed cryoglobulinaemia: a case report

HCV infection has been associated with a broad spectrum of extrahepatic manifestations. In some of these, such as mixed cryoglobulinaemia (MC), the association is firmly established, whereas in others, such as polyarteritis nodosa (PAN), it is anecdotal; in fact, in this disorder the importance of the association is controversial, since it seems to be related to the frequent coinfection of HBV and HCV. The pathogenesis of MC and PAN is far from clear, but recent developments have added a plethora of information on the mechanisms underlying these disorders. Although both could be induced by a viral infection, the pathophysiological processes underlying the two diseases are different. We describe the occurrence in the same patient of HBV-related PAN and HCV-related MC.

Polymyositis occurring during alpha-interferon treatment for malignant melanoma: a case report and review of the literature

Polymyositis is a systemic autoimmune disorder characterised by proximal muscle weakness which most frequently involves the limbs, neck and trunk. Alpha interferon is an antiviral molecule with well-known immunomodulatory and antiproliferative effects, but its use is often associated with a variety of side effects, in particular autoimmune phenomena. We report the occurrence of polymyositis during treatment with alpha-interferon in a patient affected by malignant melanoma. Indirect evidence suggests that in this case the patient's myositis was not linked to her neoplasia, since the melanoma was confirmed to be in remission both at the time of the diagnosis of the muscle disease and again after more than one year of follow-up.