AB0836 Micronutrients deficiencies in Enteropathic Spondyloarthritis: the interplay with metabolism and HLA-B27 in disease phenotype

Background

Micronutrients play immunomodulatory roles through interactions with innate and adaptive immunity influencing the pro/anti-inflammatory balance. Serum levels depend on multiple factors such as gender, nutrition, and gut microbiome. Micronutrient deficiencies (MNDs) are associated with a pro-inflammatory status and co-morbidities in patients with chronic inflammatory diseases. No studies focused on potential interplay between MNDs and disease phenotype in Enteropathic Spondyloarthritis (ESpA) in which the combination of SpA with inflammatory bowel diseases (IBD) might dramatically affect micronutrients status.

Objectives

We analysed the occurrence of anemia (Hb ≤12 g/dl) and deficiencies of ferritin (Fe, ≤15 ng/dL), vitamin D [25(OH)D, ≤20 ng/ml], vitamin B12 (VB12, ≤200 pg/ml), and folic acid (FA, ≤ 4ng/mL) in ESpA patients. The interplay of MNDs with gender, metabolic parameters, HLA-B27 susceptibility, type of SpA and IBD, disease activity, and treatments was also explored.

Methods

Selection criteria of this cross-sectional descriptive study consisted of having a diagnosis of ESpA, regardless of its type, in an age of ESpA onset ≥18 and ≤80 years, among patients who were admitted to a combined Gastro-Intestinal and RHEumatologic “GI–Rhe” clinic (Tor Vergata University Hospital, Rome, Italy). Exclusion criteria were represented by active IBD, pregnancy or lactation, kidney and/or liver failure, alcohol abuse, neoplasia, ongoing supplementations. SpA disease activity was assessed by ASDAS-CRP and functional status by HAQ-S. All the enrolled patients underwent blood chemistry analysis to determine parameters including CRP, uric acid (SUA), Fe, 25(OH)D, VB12, FA, and HLA-B27 typing.

Results

We included 164 patients comprising 109 females and 55 age-matched males. A diagnosis of Crohn’s Disease (CD) occurred in 70% of patients while Ulcerative Colitis (UC) represented a third of the cohort. Peripheral (per) and axial (ax) SpA were equally distributed (50%vs50%). Patients with ax-SpA displayed a greater prevalence of CD than UC (p=0.02) while UC was prevalent in per-SpA (p=0.02). B27+ was revealed in 19% of our cohort: B27+ patients had a higher prevalence of ax-SpA (p=0.016) and a more severe disease activity (p=0.02) than B27-. Moreover, B27 positivity and uveitis were prevalent in ax-SpA compared to per-SpA (p=0.009 and p=0.01, respectively). According to univariate analysis, males showed higher SUA (P=0.004) and BMI (p=0.03) than females. Conversely, females showed a higher prevalence of anemia than males (p=0.002). A third of ESpA cohort showed FA (31.6%) and 25(OH)D (27.8%) deficiency while VB12 defect was less frequent (18.2%) and was registered almost entirely in B27- ESpA (p=0.02). CD-ESpA showed a lower mean VB12 (p=0.04) and a higher prevalence of ocular/skin co-morbidities (p=0.02) and ax-SpA (p=0.04) than UC-ESpA. Accordingly, CD-ESpA were on bDMARDs more than UC-ESpA (p=0.04).

Conclusion

Our findings document that FA and 25(OH)D deficiencies represent the main MNDs among ESpA patients while VB12 seems to be deficient mostly in patients with CD and almost exclusively in B27- patients. Otherwise, B27+ in ESpA results to be associated mainly with disease phenotype and treatments. In ESpA, the gender of patients appears to impact principally on dysmetabolism highlighting the role for nutritional interventions particularly in males. The interplay of MNDs with B27 and dysmetabolism in ESpA deserves further investigations also taking into account CD/UC localization and behavior.

References

[1]Park YE, et al. Incidence and risk factors of micronutrient deficiency in patients with IBD and intestinal Behçet’s disease: folate, vitamin B12, 25-OH-vitamin D, and ferritin. BMC Gastroenterol. 2021;21(1):32.doi: 10.1186/s12876-021-01609-8.

[2]Conigliaro P, et al. Impact of a multidisciplinary approach in enteropathic spondyloarthritis patients. Autoimmun Rev. 2016;15(2):184-90.doi: 10.1016/j.autrev.2015.11.002.

Disclosure of Interests

None declared

SARS-CoV-2 Igg seroprevalence in IBD patients treated with biologics: first vs. second pandemic wave in a prospective study

OBJECTIVE

In a prospective study, SARS-CoV-2 IgG seroprevalence was assessed during the second pandemic wave (W2) in a cohort of Inflammatory Bowel Disease (IBD) patients using biologics. The secondary aim was to compare, in the same cohort, the frequency of seropositivity and of COVID-19 during the second vs. the first (W1) wave.

PATIENTS AND METHODS

From November 2020 to March 2021, SARS-CoV-2 IgG seropositivity and the prevalence of COVID-19 were assessed in a cohort of IBD patients using biologics already studied at W1.

INCLUSION CRITERIA

age ≥ 18 years; diagnosis of IBD; follow-up; written consent.

EXCLUSION CRITERIA

SARS-CoV-2 vaccination. Risk factors for infection, compatible symptoms, history of infection or COVID-19, nasopharyngeal swab test were recorded. Data were expressed as median [range]. The χ2 test, Student's t-test, logistic regression analysis was used.

RESULTS

IBD cohort at W1 and W2 included 85 patients: 45 CD (52.9%), 40 UC (47.1%). When comparing the same 85 patients at W2 vs. W1, a higher SARS-CoV-2 seroprevalence at W2 was at the limit of the statistical significance (9.4% vs. 2.3%; p=0.05). The prevalence of COVID-19 at W2 vs. W1 was 3.5% (3/85) vs. 0% (0/85) (p=0.08). Contacts with COVID-19 patients and symptoms compatible with COVID-19 were more frequent at W2 vs. W1 (18.8 % vs. 0%; p=0.0001; 34.1% vs. 15.3%; p=0.004). At W2, history of contacts and new onset diarrhea were more frequent in seropositive patients [4/8 (50%) vs. 12/77 (15.6%); p=0.01 and 4/8 (50%) vs. 2/77 (2.6%); p=0.0001]. At W2, the risk factors for seropositivity included cough, fever, new onset diarrhea, rhinitis, arthromyalgia, dysgeusia/anosmia at univariate (p<0.05), but not at multivariate analysis. History of contacts was the only risk factor for seropositivity at univariate (p=0.03), but not at multivariate analysis (p=0.1).

CONCLUSIONS

During W2, characterized by a high viral spread, IBD and biologics appeared not to increase the prevalence of SARS-CoV-2 infection or COVID-19 disease. New onset diarrhea mimicking IBD relapse may be observed in patients with SARS-CoV-2 infection.

Low prevalence of SARS-CoV-2 infection in inflammatory bowel disease

OBJECTIVE

Treatments used in Inflammatory Bowel Disease (IBD) have been associated with enhanced risk of viral infections and viral reactivation, however, it remains unclear whether IBD patients have increased risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. The aim of the study was to examine the prevalence of SARS-CoV-2 IgG positivity in IBD patients followed at our referral center. The role of treatments for IBD and risk factors for infection were also evaluated.

PATIENTS AND METHODS

In a prospective study, all IBD patients followed at our referral centre between May 27th and July 21st, 2020 and fulfilling the inclusion criteria were tested for SARS-CoV-2 IgG. Specific IgG antibodies were evaluated by a commercial ELISA kit and SARS-CoV-2 nasopharyngeal swab was performed in seropositive patients.

RESULTS

Two-hundred and eighteen patients, 128 Crohn's disease (CD) and 90 Ulcerative colitis (UC) [age 44, (19-77) years; ongoing biologics in 115 (52.7%)] were enrolled. No patient had major SARS-CoV-2-related symptoms. SARS-CoV-2 IgG were detected in 3 out of 218 (1.37%) patients with IBD (2 CD and 1 UC), all on biologics (2.6%). In all of the 3 seropositive patients, the nasopharyngeal swab was negative. There was no relationship between SARS-CoV-2 seroprevalence and the demographic/clinical characteristics of IBD patients. In contrast, history of recent travel was more frequent in the SARS-CoV-2 seropositive patients (2/3; 66.6%) than in SARS-CoV-2 seronegative patients [7/215 (3.25%); p<0.0001].

CONCLUSIONS

The prevalence of SARS-CoV-2 IgG seropositivity in IBD patients appears to be comparable to the non-IBD population and not influenced by ongoing treatments. Risk factors for infection common to the general non-IBD population should be considered when managing patients with IBD.

Endoscopic vs ultrasonographic findings related to Crohn's disease recurrence: a prospective longitudinal study at 3 years

BACKGROUND AND AIMS

Ileocolonoscopy (IC) is the gold standard for assessing Crohn's Disease (CD) recurrence after ileo-colonic resection. In a prospective longitudinal study we compared findings related to CD recurrence when using techniques visualizing either the luminal or the extraluminal surface (IC and small bowel follow through, SBFT vs Small Intestine Contrast Ultrasonography, SICUS).

METHODS

From 2003 to 2008, 25 CD patients undergoing ileo-colonic resection were enrolled. Clinical assessment (CDAI) was performed at 1, 2 and 3 years. IC was performed at 1 (n=25) and 3 years (n=15), SBFT at 2 years (n=21) and SICUS at 1 (n=25), 2 (n=21) and 3 years (n=15). Recurrence was assessed by SBFT and SICUS (bowel wall thickness, BWT) when using IC as gold standard.

RESULTS

At 1 year, all patients were inactive and recurrence was detected by IC in 24/25 (96%) and by SICUS in 25/25 patients. At 2 years, 6/21 patients (29%) were active and recurrence was detected by SBFT in 12/21 (57%) and by SICUS in 21/21 patients. At 3 years, 5/15 patients (33%) were active, IC showed recurrence in 14/15 (93%), and SICUS in 15/15 patients. The endoscopic score at 1 year was higher in patients developing relapse at 2 years (n=5) than in patients maintaining remission (n=10) (median: 4, range 3-4 vs 2, range 0-3; p=0.003). The same finding was not observed by using SICUS (median BWT at 1 year: 5, range 4-7 vs 3.7, range 3.5-6; p=0.19).

CONCLUSIONS

Although IC and SICUS provide a different view of the bowel wall, in experienced hands SICUS provides findings compatible with endoscopic recurrence after ileo-colonic resection for CD. Discrepant findings may be observed in a low proportion of patients with minor lesions related to CD recurrence.

Perforated jejunal diverticulitis: personal experience and diagnostic with therapeutical considerations

A case of perforated jejunal diverticulitis in a 87-year-old man is described and the literature is reviewed. Jejunal diverticulosis (JD) is estimated to occur in 0.02% to 1.3% of the adult population and is found most often in the elderly. The acute diverticulitis with perforation has been reported as high as 2.3% among patients with JD and is associated with high mortality. Clinical presentation mimic other more common acute intraperitoneal inflammatory conditions. Enteroclysis and abdominal CT are the most specific diagnostic tests. The common treatment is surgical resection of the involved segment. Laparoscopic resection and medical and medical/radiological approaches have also been proposed. Diagnostic and therapeutical aspects of this pathology are discussed.

[Non-Hodgkin's lymphoma, renal carcinoma, and meningioma. A clinical case]

Some second malignant neoplasms are increasingly being observed following NHL and a considerable amount of data has accumulated in the literature. The authors describe a case of 65-year old male who presented with submandibular adenopathy. Results of a biopsy of the mass surgically removed revealed low grade non-Hodgkin lymphoma. During the staging workup, a meningioma and a renal cell adenocarcinoma (RCC) were unexpectedly discovered and successively resected. The patient is currently alive with no evidence of metastatic diseases 12 months after diagnosis of non-Hodgkin's lymphoma (NHL), 10 months after meningioma resection and 8 months after RCC resection. The possibility of an underlying pathologic mechanism predisposing to multiple tumours should be considered. RCC and central nervous system (CNS) neoplasms are among second malignancies with higher incidences in non-Hodgkin lymphoma patients whereas with specific regard to meningioma, one of the most common benign intracranial tumours that sometimes shows biological aggressiveness and malignancy, we have currently no data in the literature. Increased risks for several malignancies occur late in the NHL follow-up period and are largely confined to patients receiving either radiation therapy or chemotherapy. On the other hand, increased risks for renal cancer have also been reported at less than one year after diagnosis of NHL and are present in all treatment subgroups (radiation therapy, chemotherapy, other-no treatment). Increased risks for CNS malignant neoplasms have also been reported at less than one year. The authors review the pathogenic significance of this case report neoplasms association in the light of the various explicative hypothesis of this concurrence. Possible immune mechanisms associated with these neoplasm are particularly pointed up.

[Thyroid cancer and Hashimoto's thyroiditis]

In a 45 years old women affected by Hashimoto's thyroiditis appeared a thyroid nodule that at the cytologic and than at the histologic examination proved to be a papillar carcinoma. Concerning this problem the authors make a thorough analysis of the literature. Regarding the possible associations between these two diseases, they observe how there is an extreme discordance of opinions on considering statistically significant the relationship between thyroid cancer and Hashimoto's thyroiditis. They make the hypothesis that the association of these two diseases is not casual: several etiological factors could be considered, but the chronic stimulus of TSH on the thyroid tissue affected by the autoimmune disease and progressively hypofunctioning, could be the main factor responsible for the development of the neoplasia. Then they give some advice to recognise patients at high risk for thyroid carcinoma. The patients at higher risk for thyroid cancer are those that present a single or prevalent nodule; the growth of a nodule on suppressive treatment with levothyroxine is also a negative prognostic index. Patients with an enlarged gland without nodules or with nodular goiter without a prevalent nodule are at low risk for cancer.

[Continuous spinal analgesia in home care of oncologic pain]

The authors in this study, after a short survey of the most important therapeutic techniques for cancer pain, report their results in the treatment of 18 patients suffering from incurable disease. It was impossible to dismiss them from hospital care on account of a painful symptomatology not controllable by oral morphine or owing to excessive collateral morphinic consequences. The analgetic technique employed was continuous intrathecal infusion of morphine, clonidine, droperidol and, in 10 cases, bupivacaine. Drug delivery systems, totally internalized, except infusion pump, were always utilized. Adequate pain relief was obtained, within - 5 days, in all the patients. Family membres, in the same period, learnt the infusion circuit action. At this point the patients were dismissed and treated with home care. The average time of assistance was 140 days, and very moderate variations in posology were necessary. Hospital reentrance, really little numerous, happened only when no member of palliative care service was present. Reasons were no bodily pain, but the total suffering of cancer disease. No complication nor collateral consequences were never found.

[Operative stress and neuroendocrine changes: influence of anxiety, pain, and drugs]

In this study we took into consideration the neuroendocrine alterations caused by surgical stress, studying the cortisol and prolactin's course in plasma, during the period between preanesthesia and the morning after operation. Our research was particularly interested in identifying the influence of anxiety, pain and drugs. At this purpose, twenty-four patients (ASA 1-2) submitted to abdominal surgery, were subdivided in to two groups of twelve members each. In the first (group G) a general inhalising anesthesia with analgesic component was performed; in the second (group B) a selective peridural anesthesia associated with slight general anesthesia, the so-called blended anesthesia. The interpretation of the results showed an action particularly on prolactin, and of pain on cortisol. Thus, a proper use of anesthetic drugs, even if some of them have sure stimulating properties, is useful to reduce the hormonal response. Therefore as good is the control of anxiety and pain, so good is the hormonal metabolic reaction to surgical stress. If the measures to reduce anxiety are limited to a suitable preanesthesia (possibly combined with psychological preparation), on pain, on the contrary, it is possible to act with suitable technology, first of all by locoregional anesthesia. It is, however, important to underline that the best therapy of pain is its prevention.

Quantification of human immunodeficiency virus type 1-infected mononuclear cells in peripheral blood of seropositive subjects by newly developed flow cytometry analysis of the product of an in situ PCR assay

The presence of human immunodeficiency virus type 1 (HIV-1) proviral DNA in peripheral blood mononuclear cells (PBMC) of three groups (group 1, more than 500 CD4+ T cells per microliter; group 2, between 200 and 499 CD4+ T cells per microliter; group 3, fewer than 200 CD4+ T cells per microliter) of HIV-1-infected patients, in different stages of the disease, was determined by using a newly developed flow cytometry analysis of the product of in situ PCR assay and compared with other markers of viral replication (HIV-1 p24 antigenemia and viral isolation). Results showed varied percentages of HIV-1-infected PBMC, ranging from 0.6 to 20%. Patients with more than 500 CD4+ T cells per microliter showed the lowest percentage of HIV-1-infected PBMC (2.1 +/- 1.7), compared with patients with CD4+ T-cell counts of between 200 and 499 per microliter (6.5% +/- 4.1%; P < 0.001) and patients with fewer than 200 CD4+ T cells per microliter (4.9% +/- 4.7%; P < 0.05). The difference in the percentage of HIV-1-infected PBMC between group 2 and group 3 patients may in part reflect the loss of CD4+ T lymphocytes in more advanced stages of the disease. However, the results clearly indicate a striking coincidence between the fall of the CD4+ T-cell count below 400/microliter and the sharp increase in PBMC virus loading and p24 antigenemia. Since the procedure is relatively easy to perform, it could be used to monitor the evolution of HIV-1 infection and may prove a useful adjunct in tailoring therapeutic strategies.

[Tumoral calcinosis. A case report]

A case of tumoral calcinosis of the hand is reported. The lesion was localized at the fifth digit of the right hand and caused pain and disability. The clinical, diagnostic and therapeutic problems of this rare soft tissue disease are discussed.

Reduction of neutral gene flow due to the partial sterility of heterozygotes for a linked chromosome mutation

The effect of linkage between a chromosome mutation producing partially sterile heterozygotes and a neutral locus in reducing the gene flow at the neutral locus is studied using a two-population deterministic model. Chromosome mutations are more efficient in reducing gene flow with low migration rates than with high ones. The interaction between high values of partial heterozygote sterility and low recombination rates can produce, in the low migration pattern, a drastic reduction of gene flow. Nevertheless, since only chromosome mutations with low values of partial heterozygote sterility are likely to be involved in chromosomal speciation, a significant reduction of gene flow will probably occur only for a very limited part of the genome. Therefore, a single chromosome mutation is unlikely to play a primary role in speciation.