Influence of locally delivered doxycycline on the clinical and molecular inflammatory status of intrabony defects prior to periodontal regeneration: A double-blind randomized controlled trial

OBJECTIVES

To test the effect of locally delivered doxycycline (DOX) administered 2 weeks prior to minimally invasive periodontal regeneration in terms of presurgical inflammatory status and cytokine expression profile in the gingival crevicular fluid (GCF). Secondary aim was to assess the early wound healing index (EHI) at 2 weeks after surgery.

BACKGROUND

It is hypothesized that healing after periodontal regeneration is dependent on preoperative soft tissue condition, and that local antibiotics may improve the site-specific inflammatory status at short time.

METHODS

Sites associated with periodontal intrabony defects requiring regenerative surgery and showing bleeding on probing (BoP) were included. At T0, experimental sites were randomly treated with subgingival instrumentation with or without topic DOX application. After 2 weeks (T1), defects were approached by means of minimally invasive surgical technique. GCF was sampled at both T0 and T1 for inflammatory biomarker analysis. Two weeks after surgery, the EHI was evaluated (T2).

RESULTS

Forty-four patients were included. At T1, the number of BoP+ sites was statistically significantly less in the test group (27.3% vs. 72.7%; p < .01). The total amount of interleukin (IL)-1β (p < .001), matrix-metalloproteinases (MMP)-8 (p < .001), and MMP-9 (p = .010) in the GCF significantly decreased in the test group at T1, with relevant differences compared to controls. At T2, the EHI had an average value of 1.45 ± 0.86 in the test group while in the control, it was 2.31 ± 1.43 (p = .027). A statistically significantly positive correlation was observed between the amount of IL-1β and MMP-9 and EHI scores.

CONCLUSIONS

Within the limitations of this study, sites treated with DOX showed improved clinical and molecular inflammatory parameters before surgery, as well as soft tissue healing 2 weeks after surgery.

Pediatric-Onset Chronic Inflammatory Demyelinating Polyneuropathy: A Multicenter Study

BACKGROUND

To evaluate the clinical features, demographic features, and treatment modalities of pediatric-onset chronic inflammatory demyelinating polyneuropathy (CIDP) in Turkey.

METHODS

The clinical data of patients between January 2010 and December 2021 were reviewed retrospectively. The patients were evaluated according to the Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Society Guideline on the management of CIDP (2021). In addition, patients with typical CIDP were divided into two groups according to the first-line treatment modalities (group 1: IVIg only, group 2: IVIg + steroid). The patients were further divided into two separate groups based on their magnetic resonance imaging (MRI) characteristics.

RESULTS

A total of 43 patients, 22 (51.2%) males and 21 (48.8%) females, were included in the study. There was a significant difference between pretreatment and post-treatment modified Rankin scale (mRS) scores (P < 0.05) of all patients. First-line treatments include intravenous immunoglobulin (IVIg) (n = 19, 44.2%), IVIg + steroids (n = 20, 46.5%), steroids (n = 1, 2.3%), IVIg + steroids + plasmapheresis (n = 1, 2.3%), and IVIg + plasmapheresis (n = 1, 2.3%). Alternative agent therapy consisted of azathioprine (n = 5), rituximab (n = 1), and azathioprine + mycophenolate mofetil + methotrexate (n = 1). There was no difference between the pretreatment and post-treatment mRS scores of groups 1 and 2 (P > 0.05); however, a significant decrease was found in the mRS scores of both groups with treatment (P < 0.05). The patients with abnormal MRI had significantly higher pretreatment mRS scores compared with the group with normal MRI (P < 0.05).

CONCLUSIONS

This multicenter study demonstrated that first-line immunotherapy modalities (IVIg vs IVIg + steroids) had equal efficacy for the treatment of patients with CIDP. We also determined that MRI features might be associated with profound clinical features, but did not affect treatment response.

AB0748 Anti-Fibrotic Therapy in Progressive Pulmonary Fibrosis Associated with Sytemic Sclerosis: Characteristics of SSc-İAH Patients Receiving Nintedanib and Advers Events during Treatment

Background

Nintedanib, an intracellular inhibitor of tyrosine kinases, has been recently approved for interstitial lung disease associated with systemic sclerosis (SSc-ILD). Nintedanib has shown antifibrotic and antiinflammtory effects in animal models of fibrosing ILDs.

Objectives

We aimed to evaluate clinical charcteristics of progressive SSc-ILD patients receiving anti-fibrotic therapy who were resistant to standart immunosuppressives (ISs) and adverse events during treatment period in this cohort.

Methods

Fifteen patients fulfilling ACR/EULAR (2013) classification criteria for SSc and receiving nintedanib for progressive ILD despite standart ISs included into this retrespective analysis.

Results

Demographics and clinical characteristics of SSc patients were summarised in Table 1. Median age, duration of Raynaud’s and duration of non-Raynaud symptom were 49 (35-72), 8 (1-30) and 4 years (1-21), respectively. ILD was evident median 2 years (0.5-20) after onset of Raynaud’s and 1 years (0.5-11) after onset of non-Raynaud symptom. Before pulmonary involvement, 7 patients received methotrexate and 1 patient cyclophosphamide (CYC) for diffuse cutaneous involvement. After evident ILD, 6 patients received CYC, 5 patients mycophenolate mofetil (MMF) and 4 patients azathioprine as first ISs for SSc-ILD. Median FVC(%) and DLCO(%) were 56 (39-67) and 44 (20-67) before antifibrotic therapy. Thirteen patients (%92,8) received ≥2 ISs before nintedanib. Duration of evident ILD to onset of antifibrotic therapy was median 5.5 years (2-11). Nintedanib was prescribed concomitantly with MMF in 8 or rituksimab-MMF in 6 patients. Median follow-up of antifibrotic treatment period was 7 months (2-18). Advers events during nintedanib were summarised in Table 2. One patient was deceased due to small cell lung cancer at 9.month of nintedanib.

Table 1.

Characteristics of SSc-ILD Patients Receiving Nintedanib

n (%)Females12 (80)Clinical CharacteristicsDiffuse Cutaneous SSc13 (86.7)Limited Cutaneous SSc2 (13.3)Synovitis3 (20)Digital ulsers8 (53.3)Pulmonary arterial pressure >30 mmHg (echo)5 (30)Gastrointestinal involvement10 (76.9)SerologyANA13(86.7)Anti-Scl7010 (66.7)ImmunosuppressivesCYC8 (53.3)MMF14 (93.3)AZA7 (46.7)MTX6 (40)RTX6 (40)Low dose steroids15 (100)Table 2.

Advers Events during Nintedanib Treatment in SSc-ILD patients

SSc-ILD (n=15)Any advers events n(%)8 (53.3) Diarrhoea5 (30) Nausea/ vomiting1 (6.7) Abdominal pain3 (20) Weight decreased3 (20) Yorgunluk2 (13.3) Cough3 (20) Infections (pneumonia)3 (20) Liver test abnormalities4 (26.7) Malignancy1 (7.1) Dose reduction and reescalation7 (46.7) Dose interruption2 (13.3)

Conclusion

Nintedanib was prescribed in progressive SSc-ILD patients who had predominatly diffuse cutaneous involvement, anti-SCL70 positivity and exposed to multiple standart ISs. Duration of ISs were higher than 5 years before antifibrotic therapy. Gastrointestinal (GI) advers events were frequent during nintedanib requiring dose reduction in half of the patients. Nintetanib can be used in progressive SSc-ILD patients considering some difficulties in such a disease with GI involvement. Efficacy analysis of the antifibrotic therapy needs further studies including long term follow-up.

Disclosure of Interests

None declared

AB1082 FREQUENCY AND SEVERITY OF COVID-19 IN PATIENTS WITH VARIOUS RHEUMATIC DISEASES TREATED REGULARLY WITH COLCHICINE OR HYDROXYCHLOROQUINE

Background

Several anti-inflammatory drugs which were targeted different mechanisms and investigated for both prevention and treatment for COVID-19.

Objectives

The current study aimed to investigate whether patients regularly using colchicine or hydroxychloroquine (HCQ) have an advantage of protection from COVID-19 or developing less severe disease.

Methods

Patients who were taking colchicine or HCQ regularly for a rheumatic disease including Familial Mediterranean Fever, Behçet’s syndrome, Systemic Lupus Erythematosus, Rheumatoid Arthritis and Sjogren’s syndrome as well as their healthy household contacts as the control group were included into the study. The clinical data regarding COVID-19 were collected using a standard form, and serum samples were analyzed for anti-SARS-COV-2 nucleocapsid IgG. Patients treated with any biologic or immunosuppressive treatments were not included into the study.

Results

A total of 635 regular colchicine users with their 643 household contacts and 317 regular HCQ users with their 333 household contacts were analyzed. Anti-SARS-Cov2 IgG was positive in 43 (6.8%) regular colchicine users and 35 (5.4%) household contacts (OR=1.3; 95% CI:0.8-2; p=0.3) (Table 1). COVID-19 related symptoms were described by 29 (67.4%) of the patients and 17 (48.6%) household contacts (OR=2.2; 95% CI:0.9-5.5; p=0.09), and hospital admission was observed in five (11.6%) and one (2.9%) of these subjects (OR=4.5; 95% CI:0.5-40.2; p=0.1), respectively (Figure 1). Seropositive subjects were observed in 22 (6.9%) regular HCQ users and 24 (7.2%) household contacts (OR=1.1; CI:0.6-1.9; p=0.8) (Table 1). COVID-19-related symptoms occurred in 16 (72.7%) of the 22 patients and 12 (50%) of 24 household contacts (OR=2.7; 95% CI:0.8-9.1; p=0.1). Three patients (13.6%) were admitted to hospital, while one household contact (4.2%) was hospitalized (OR=3.6; 95% CI:0.3- 37.8; p=0.2) (Figure 1). Disease-specific analyses disclosed that there was no significant difference in terms of COVID-19 frequency and severity between a particular disease subset and household contacts (Table 1). Univariate logistic regression analysis showed no effect of age and gender on the SARS-CoV-2 seroprevalence rate among regular colchicine or HCQ users and household contacts (p=0.2 and p=0.7, respectively for colchicine users versus contacts, p=0.7 and p=0.3, respectively for HCQ users versus contacts).

Figure 1.

Severity of COVID-19 in regular colchicine or HCQ users and these patients’ household contacts

Table 1.

Disease specific outcomes of the entire cohort

VariableFMF (n=373)FMF HHC* (n=386)PBehcet Patients (n=262)Behcet HHC (N=257)PSLE Patients (N=197)SLE HH (n=221)pRA Patients (n=79)RA HH (n=73)PSjögren patients (N=41)Sjögren HH (N=39)pAge, mean ± SD years36.4 ± 13.236.3 ± 16.10.942.9 ± 11.438.1 ± 15.20.00144.2 ± 12.639.4 ± 170.00253.9 ± 10.340.3 ± 16.60.00157.1 ± 11.246.2 ± 16.10.001Gender, n (%) Female249 (66.8)173 (44.8)0.001160 (61.1)118 (45.9)0.001184 (93.4)75 (33.9)0.00173 (61.1)20 (27.4)0.00141 (100)10 (25.1)0.001Positive antibody to SARS-COV-2, n (%)25 (6.7)23 (5.9)0.618 (6.9)12 (4.7)0.314 (7.1)19 (8.6)0.64 (5.1)2 (2.7)0.54 (9.8)3 (7.7)0.9Symptomatic COVID-19 in seropositive cases, n (%)18 (72)10 (43.4)0.0411 (61.1)7 (58.3)0.611 (78.6)9 (47.3)0.073 (75)0 (0)0.42 (50)3 (100)0.4Hospital admission in seropositive cases, n (%)1 (3.8)0 (0)-4 (22.2)1 (8.3)0.32 (14.3)0 (0)0.21 (25)0 (0)-1 (25)1 (33.3)0.3Mean colchicine dose, mg/day ± SD1.5 ± 0.4--1.4 ±0.4-----------Mean duration of colchicine usage, years ± SD11.3 ± 8.3--10.4 ± 7.7-----------Mean HCQ dose, mg/day ± SD------263.6 ± 95.1--255 ± 90.8--273.7 ± 132.5--Mean duration of HCQ usage, years ± SD------10.1 ± 6.6--7.3 ± 5.2--9 ± 6.3--

HCQ hydroxychloroquine, FMF familial mediterranean fever, HHC household contacts, RA rheumatoid arthritis, SLE systemic lupus erythematosus

Conclusion

Being on a regular treatment of colchicine or HCQ was not resulted in the prevention of COVID-19 or amelioration of its manifestations.

Disclosure of Interests

None declared

POS1279 FAVOURABLE COURSE OF COVID-19 IN PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER USING BIOLOGIC AGENTS

Background

Serious infections are more frequently seen in patients with inflammatory rheumatic diseases, being treated with immunosuppressive or biologic disease-modifying antirheumatic drugs (b-DMARDs). Potential harmful effects of immunosuppressive drugs as well as b-DMARDs were a major concern during the early phases of the Coronavirus disease 2019 (COVID-19) pandemic, and preliminary data documented the worse outcome of COVID-19 associated with B cell depleting treatments (1). On the other hand, limited information has been shared about the course of COVID-19 in patients with monogenic autoinflammatory disorders using IL-1 inhibitors.

Objectives

We herein aimed to evaluate the course of COVID-19 in adult patients with the most common form of inflammasomopathy, Familial Mediterranean Fever (FMF), who were on biologic agents.

Methods

In this cross-sectionally study, FMF patients were evaluated by screening their clinical and electronic records in our database in October 2021. The FMF patients with a record of PCR-confirmed COVID-19 were investigated in more detail in our hospital. Characteristics of FMF findings as well as clinical and laboratory findings associated with COVID-19 were recorded from the outpatient follow-up cards.

Results

We identified 184 FMF patients using biologic agents, and their baseline characteristics are summarized in Table 1. Among them, 36 had PCR-confirmed COVID-19; 32 of them were currently on b-DMARD along with colchicine (31 anti-IL-1, 1 anti-TNF), and 4 of them had a previous history of b-DMARD treatment. Data about the course of COVID-19 could be reached in 34 patients. Four (11%) patients had an asymptomatic course. Remaining patients with symptomatic COVID-19 had the following symptoms: cough (50%), headache (47.2%), fever (44.4%), loss of taste and smell (41.6%), myalgia (0.6%), dyspnoea (27.8%), diarrhea (25%) abdominal pain (5.6%). Thorax computed tomography was performed in 10 patients, and findings of pneumonia were documented in 6 (16.7%). The mean values of the laboratory parameters were as follows: C-reactive protein 99.48 ± 112.66 mg/L; ferritin 316 ± 208.3; D-Dimer 2445 ± 3917, Lactate Dehydrogenase 253 ± 61, troponin T 26 ± 20, procalcitonin 0.348 ± 0.53. Lymphopenia was detected in 5 (13.9%) patients; mean lymphocyte count was 1080 ± 363. Data about the treatment could be reached in 34 patients. Antiviral therapy was prescribed in 25 (69.4%) patients (favipiravir, n=22; and oseltamivir, n=3). Antibiotics were given to 6 (16.7%) patients, and 6 (16.7%) received hydroxychloroquine. Parenteral steroids were administered to 2 patients during the hospitalization. Six (16.7%) patients required hospitalization, and 2 (5.6%) required oxygen support, non-invasive mechanical ventilation, and one of them followed in the intensive care unit. Twenty-two patients were on anakinra treatment, and none of them required additional dose. Only 1 patient, a 61-year-old male patient with a history of lung lobectomy and renal transplantation, received tocilizumab due to macrophage activation syndrome, and he later died of sepsis. This patient was on anakinra until 2 years before, and it was discontinued due to an allergic reaction. Only 4 patients had a history of vaccination before COVID-19, and none of them developed pneumonia and required hospitalization. Six patients had FMF attacks after recovering from COVID-19. None of the patients developed thromboembolism and secondary bacterial infections.

Conclusion

This survey identified 36 biologic b-DMARD receiving FMF patients, who had COVID-19. All but 1 patient had complete recovery, and b-DMARD usage did not negatively affect the COVID-19 course. None of the patients currently on anti-IL-1 or anti-TNF had a worse outcome. Based on these observations, it can be suggested that refractory FMF patients can continue their b-DMARD treatments when they had COVID-19.

References

[1]Jérôme Avouac, Elodie Drumez, Eric Hachulla, Raphaèle Seror, Sophie Grorgian-Lavialle, et al. COVID-19 outcomes in patients with inflammatory rheumatic and musculoskeletal diseases trated with rituximab: a cohort study. Lancet Rheumatol 2021 Published Online March 25, 2021, https://doi.org/10.1016/S2665-9913(21)00059-X

Disclosure of Interests

None declared

AB1299 DIFFERENCES IN THE CLINICAL SPECTRUM OF HAPLOINSUFFICIENCY OF A20 (HA20) CASES DIAGNOSED DURING ADULTHOOD

Background

Haploinsufficiency of A20 (HA20) is a monogenic autoinflammatory disease caused by heterozygous loss-of-function mutations in TNFAIP3 gene and characterized by Behçet disease (BD)-like manifestations such as mucocutaneous, articular, gastrointestinal, ocular symptoms as well as recurrent fever, elevated acute-phase reactants during relapses; and it usually starts during early childhood. Autoimmunity is another component of HA20 with autoantibodies and variable clinical features resembling systemic lupus erythematosus (SLE) and other autoimmune diseases.

Objectives

We herein present three cases of HA20 with different clinical features and diagnosed during adulthood.

Methods

We used the Ion Torrent platform for deep sequencing.

Results

Case 1: A 51-year old woman diagnosed with BD because of oral and genital aphthous ulcers, arthralgias, erythema nodosum, and pathergy positivity starting from age of 40 in 2012. She developed sudden vision loss (diagnosed with bilateral optic neuropathy), sixth nerve palsy, and entrapment neuropathies in the lower limbs in 2014; and she had flares of neurologic findings between 2014-2020. The only laboratory abnormality was elevated acute-phase reactants, and no pathologic finding was reported for cranial MRI. Pathological examination of sural nerve biopsy revealed chronic inflammatory demyelinating polyneuropathy (CIDP). She received adalimumab and then tofacitinib, and her treatment was switched to certolizumab and IVIG (30 g/6 weeks) in 2020. At the last visit, she was asymptomatic with normal acute phase response, and her examination revealed normal eye movements.

Case 2: A 33-year old woman was followed for 12 years with the diagnosis of SLE, based on fever, photosensitivity, alopecia, polyarthritis, serositis, positive anti-nuclear antibody (ANA) at a titer of 1:1280 with a homogeneous pattern, positive anti-dsDNA, anti-Sm, anti-Sm/RNP, and lupus anticoagulant test, and leukopenia, lymphopenia, hypocomplementemia in 2008. She developed shrinking lung syndrome and Jaccoud arthropathy during the disease course. She received several drugs including corticosteroids, hydroxychloroquine, cyclophosphamide, mycophenolate mofetil, belimumab, rituximab, tocilizumab, abatacept, tofacitinib because of fever, arthritis, skin rash, increased acute-phase reactants, pancytopenia, anti-dsDNA positivity. Her fever, red arthritis attacks with high CRP values did not respond, and after the genetic diagnosis of HA20, anakinra was added to treatment. Due to the high dose anakinra requirement, her treatment was switched to canakinumab (150 mg/2 week), and at the last visit, her attacks were significantly reduced.

Case 3: A 44-year old woman was evaluated because of recurrent prolonged >38°C fever attacks (2 days-2 weeks duration), arthritis of the elbow, wrist, knee joints, and high acute phase reactant in 2004. She did not have a history of recurrent oral and genital aphthous ulcers, intermittent periorbital edema, rash, any ocular symptoms, or sensorineural hearing loss. ANA, RF, anti-CCP, and MEFV gene mutation were negative on admission. PET-CT demonstrated FDG uptake in the wall of the ascending aorta, aortic arch, and descending aorta in 2011. She had used colchicine in 2004, etanercept between 2009 and 2010, anakinra in 2011, tocilizumab in 2012, and canakinumab in 2013. She repeatedly received IV methylprednisolone pulse therapy, but she experienced a relapse of fever when she reduced the dose of methylprednisolone to <8 mg/day. Her knee arthritis did not respond to adalimumab, and she is currently on infliximab treatment since 2019 with a Daily methylprednisolone dose of 8-12 mg.

Conclusion

HA20 can be diagnosed even in adult patients, and the clinical picture of presented cases suggests that monogenic autoinflammatory disorders including HA20 should be suspected in any patient with flares of described manifestations along with strong acute phase response even in adults. Response to corticosteroids and targeted treatments may also be variable.

Disclosure of Interests

None declared

POS1259 FAVOURABLE SHORT-TERM COURSE OF COVID-19 IN PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER USING BIOLOGIC AGENTS

Background:

COVID-19 runs a variable course resulting in acute respiratory distress syndrome and death in a subset of patients. The entry of SARS-CoV-2 into the cell stimulates innate immunity including NLRP3 inflammasome and lead to development of adaptive immunity later. Hyperinflammatory response with the release of proinflammatory cytokines including IL-1β and IL-6 results in cytokine storm in some patients with a worse outcome. Colchicine acts on NLRP3 inflammasome and inhibits and IL-1 mediated inflammatory attacks in gout and familial Mediterranean fever (FMF) patients. Patients with inadequate response to colchicine may benefit from anti-IL-1 biologic agents such as anakinra and canakinumab. Recently, favourable effects of anakinra have been observed in COVID-19 patients with findings of cytokine storm.

Objectives:

We aimed to evaluate the impact of COVID-19 among refractory FMF patients followed-up in tertiary referral with the treatment of biologic agents and also document the course of COVID-19 in these patients.

Methods:

We searched out database of FMF patients to identify those using biologic agents (anti-IL-1, anti-IL-6 or anti-TNF) for colchicine-refractory FMF. We interviewed the patients using a standard questionnaire by phone call for symptomatic COVID-19 and evaluated those patients who described findings of COVID-19 further by their hospital records or inviting them to the hospital for additional investigations.

Results:

We identified 183 patients and contacted 106 of them by phone in May-October 2020. A history of symptomatic COVID-19 was documented in 7 FMF patients who were on a biologic agent. Six were on anti-IL-1 and one was on anti-TNF, and one of the patients was not taking his biologic agents for 1 year. All of 7 patients had a favourable outcome. All but 1 patient followed at home and none of them developed findings of cytokine storm, thromboembolism and secondary bacterial infection. Hospitalized patient did not require intensive care unit (ICU) support or mechanical ventilation, and he was not given additional anti-inflammatory medications.

Conclusion:

This series of refractory FMF patients with potentially higher inflammatory characteristics showed COVID-19 did not result in a worse outcome in those patients during the first phase of the pandemic, and none developed findings of cytokine storm. Observations in these patients supports further that biologic agents blocking IL-1 and possibly TNF may contribute to the uneventful course of COVID-19 by preventing the development of hyperinflammatory response. Data collection from a larger group of patients, especially those with amyloidosis, will clarify the protective effects of colchicine and contribution of anti-IL-1 treatments on the favourable disease course during the second phase of the pandemic.

Patient 1Patient 2Patient 3Patient 4Patient 5Patient 6Patient 7Age (years)45483953323731MEFV variantsUnknownM694V/M680IUnknownM694V/ M694VM694V/ M694VM694V/ M694VM694V/ M694VAmyloidosisNoNoNoNoNoNoNoBiologic agentsAnakinra100 mg/dayNot takenfor 1 yearAdalimu-mabCanakinumab150 mg/monthAnakinra100 mg/dayCanakinumab150 mg/monthAnakinra100 mg/dayPrednisone (mg/day)5NoNoNoNoNoNoColchicine(mg/day)21,51,51,51,52,02,0RT-PCR positivityYesYesYesYesYesYesYesChest CT signsYesYesNot doneNot doneNot doneNot doneNot doneHospitalisationNoNoNoYesNoNoNoAntiviral therapyOseltamivirOseltamivirNoFavipravirFavipravirFavipravirFavipravirHCQ useYesYesYesYesNoNoNoNew FMF attackduring COVID-19NoNoNoNoNoNoNo

Disclosure of Interests:

None declared

OP0313 PRELIMINARY CRITERIA FOR MACROPHAGE ACTIVATION SYNDROME ASSOCIATED WITH CORONAVIRUS DISEASE-19

Background:

COVID-19 runs a severe disease associated with acute respiratory distress syndrome in a subset of patients, and a hyperinflammatory response developing in the second week contributes to the worse outcome. Inflammatory features are mostly compatible with macrophage activation syndrome (MAS) observed in other viral infections despite resulting in milder changes. Early detection and treatment of MAS may be associated with a better outcome. However, available criteria for MAS associated with other causes have not been helpful.

Objectives:

To identify distinct features of MAS associated with COVID-19 using a large database enabling to assess of dynamic changes.

Methods:

PCR-confirmed hospitalized COVID-19 patients followed between March and September 2020 constituted the discovery set. Patients considered to have findings of MAS by experienced physicians and given anakinra or tocilizumab were classified as the MAS group and the remaining patients as the non-MAS group. The MAS group was then re-grouped as the cases with exact-MAS and borderline-MAS cases by the study group. Clinical and laboratory data including the Ct values of the PCR test were obtained from the database, and dynamic changes were evaluated especially for the first 14 days of the hospitalization. The second set of 162 patients followed between September-December 2020 were used as the replication group to test the preliminary criteria. In the second set, hospitalization rules were changed, and all patients required oxygen support and received dexamethasone 6mg/day or equivalent glucocorticoids. Daily changes were calculated for the laboratory items in MAS, borderline, and non-MAS groups to see the days differentiating the groups, and ROC curves and lower and upper limits (10-90%) of the selected parameters were calculated to determine the cutoff values.

Results:

A total of 769 PCR-confirmed hospitalized patients were analysed, and 77 of them were classified as MAS and 83 as borderline MAS patients. There was no statistically significant difference in the baseline viral loads of MAS patients compared to the non-MAS group according to the Ct values. Daily dynamic changes in the MAS group differed from the non-MAS group especially around the 6th day of hospitalization, and more than a twofold increase in ferritin and a 1.5-fold increase in D-dimer levels compared to the baseline values help to define the MAS group. Twelve items selected for the criteria are given in Table 1 below. The total score of 45 provided 79.6% sensitivity for the MAS (including borderline cases) and 81.3% specificity around days 5 and 6 in the discovery set, and a score of 60 increased the specificity to 94.9% despite a decrease in sensitivity to 40.8%. The same set provided a similar sensitivity (80.3%) in the replication, but a lower specificity (47.4-66% on days 6 to 9) due to a group of control patients with findings of MAS possibly masked by glucocorticoids.

Table 1.

Preliminary Criteria for Macrophage Activation Syndrome Associated with Coronavirus Disease-19

1.Fever (>37.0 °C)2.Ferritin concentration > 550 ng/mL3.More than 2 times increase of ferritin concentration within 7 days of disease onset4.Neutrophil count > 6000 cell/mm35.Lymphopenia < 1000 cell/mm36.Neutrophil/lymphocyte ratio > 67.D-dimer concentration > 1000 ng/ml8.More than 50% increase of D-dimer concentration within 7 days of disease onset9.CRP concetration > 50 mg/L10.LDH concentration > 300 U/L11.ALT or AST concentration > 50 U/L12.Procalcitonin concentration < 1.2

1 point for each positive item assessed on Days 5-7

Score calculation: Total points / 12 x 100

Possible MAS ≥45 and Definite MAS ≥60

Conclusion:

This study defined a set of preliminary criteria using the most relevant items of MAS according to the dynamic changes in the parameters in a group of COVID-19 patients. A score of 45 would be helpful to define a possible MAS group with reasonable sensitivity and specificity to start necessary treatments as early as possible.

Disclosure of Interests:

None declared.

AB0448 SYSTEMIC SCLEROSIS ASSOCIATED PULMONARY ARTERIAL HYPERTENSION: PREDOMINANCE OF PULMONARY FIBROSIS AS A RISK FACTOR FOR MORTALITY IN A SINGLE CENTER COHORT

Background:

Pulmonary arterial hypertension (PAH) is a severe vasculopathic complication for systemic sclerosis (SSc) patients. The availability of oral-specific vasodilator therapies has provided better outcomes.

Objectives:

We aimed to analyze the characteristics of SSc-PAH patients and factors associated with mortality.

Methods:

Medical records of 291 SSc patients fulfilling ACR/EULAR criteria (2013) and followed–up during 2008-2020 years were screened and the patients who diagnosed PAH evaluated by right heart catheterization (mean PAB≥20 mmHg) (n=26, 8,9%) were included into this retrospective cross-sectional study.

Results:

The characteristics of 26 SSc-PAH(24 females) patients were summarised in Table 1.

Table 1.

Characteristics of SSc patients with PAH

SSc-PAH(n=26)DemographicsAge(yrs)53.6±8.9Duration of Raynaud’s(yrs)16.1±11.8Duration of Non-Raynaud’s(yrs)9.2±6.6Raynaud’s to Diagnosis of PAH(yrs)10.8±6.7Clinical Characteristics (%)LcSSc9 (34.6)DcSSc18 (65.4)Digital ulcer14 (53.8)Gastrointestinal20 (69.0)Synovitis5(19.2)Flex contractures7 (26.9)Tendon friction rubs3(11.5)Renal crisis1 (3.8)Pulmonary fibrosis19 (73.1)Auto-antibodies (%)ANA23 (88.5)Anti-centromere6(23.1)Anti-Scl7013(50)Treatment (%)Specific vasodilatorERA (bosentan/macicentan/ambricentan)15 (51.7)PDE5-i (sildenafil/tadalafil)17 (58.6)Prostacyclin-analog (İloprost/treprostenil/selexipag)15 (51.7) Riociguat5 (17.2)Immunosuppressives21(80.8)Steroids16(61.5)

Twenty-four (92,3%) of the SSc-PAH patients had PAH-related symptoms at the time of diagnosis, 2 (7,7%) were asymptomatic and diagnosed by screening. RHC and treatment details were stated in Table 2.

Table 2.

Right Heart Catheterization (RHC) ve treatment details of SSc-PAH patients

n=26Initial RHC -mean PAB30,4±7,9 (median 28, 20-53mmHg) -PVR5,1±2,4 (median 4, 3-9 woods) -PCWP10,8±5,5 (median 10, 0-15 mmHg)Initial treatment -monotherapy5 (19,2%) -combination10 (38,5%) -add-on combination12 (46,2%)

Eleven out of 26 patients (42,3 %) were deceased after a mean follow up of 43,7±24,6 (median 48,1-84) from PAH diagnosis and 15,1±9,9 (median 13, 0,6-34) years after SSc diagnosis. Deceased patients were younger and had younger age at disease onset (49,1± 8,8 vs 56,9±7,7, p=0.032 and 30,8±13,0 vs 42.0 ±10,9, 0.027). All deceased patients had associated pulmonary fibrosis (100 vs 53.3%, p=0.01). No significant difference was observed for initial RHC parameters between deceased and survived SSc-PAH patients. Specific monotherapy was found to be more frequent in deceased patients (45,5 vs 0%, p=0,007).

Conclusion:

The prevalence of SSc-PAH was found to be 8.9% with increased mortality in our cohort. SSc-PAH patients predominantly had diffuse cutaneous involvement with digital vasculopathy, pulmonary fibrosis, and anti-Scl70 positivity. PAH was diagnosed after a median of 10 years of the Raynaud’s, mainly in symptomatic patients. Mortality in PAH-SSc patients was associated with early onset of disease, pulmonary fibrosis, and monotherapy. Initial RHC parameters were not found to be related to mortality.

Disclosure of Interests:

None declared.

AB0653 COURSE OF COVID-19 INFECTION IN A SERIES OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Infection is a remarkable cause of morbidity and mortality in patients with SLE.

Objectives:

We aimed to determine the clinical course of COVID-19 infection in our patients with SLE and the factors affecting this course

Methods:

SLE patients (2012 SLICC criteria) diagnosed with COVID-19 infection by a positive PCR test and/or typical findings of lung involvement in CT (computed tomography) imaging were included. Data regarding cumulative clinical and laboratory characteristics, histopathology results, autoantibody profiles, immunsuppressives and damage (SLICC damage index/SDI)) were retrieved from the existing database and revised. SLE Disease Activity Index (SLEDAI-2K) was determined at the time of infection.

Results:

Sixteen SLE patients with COVID-19 infection were identified. Most (87.5%) of these patients were female. Seventy % (n=11) had lupus nephritis. Twenty-five % had thrombotic antiphospholipid syndrome.

PCR was positive in 70% (n=11) of the patients. Pulmonary parenchymal findings compatible with COVID-19 were observed in 56% (n=9) of those patients. Regarding complaints upon admission, 50% (n=8) had fever, 44% (n=7) cough, 44% (n=7) dyspnea, 19% (n=3) myalgia, 12.5% (n=2) headache, 12.5% (n=2) nausea /vomiting, 6% (n=1) diarrhea, and 6 % (n=1) had anosmia. Eight patients were hospitalized. Six of these patients needed oxygen therapy via nasal cannula. None needed a follow-up in the intensive care unit. The mean hospitalization duration was 14 ± 5 (8-25) days.

Regarding disease activity at the time of infection, 9 had inactive disease with a SLEDAI-2K score of 0 whilst in 5 patients SLEDA-2K score was ≥4. The mean SLEDAI-2K score at the time of infection was 1.7 ± 2.3 (0-6). System/organwise, 1 patient with chronic thrombocytopenia presented with a worsening platelet count accompanied by serologic activity. This patient was a non-adherent to treatment who had stopped taking mycophenolic acid months before COVID19. Three patients 2 of whom had proliferative nephritis experienced nephritic flares.1 patient who had a history of cutaneous lupus and was in remission presented with oral ulcer, leukopenia and hypocomplementemia during infection. Of 16 patients, 7 had system damage at the time of infection. The mean SDI score of the patients was 1.4±1.8. Comparison of patients with and without damage revealed no significant differences in disease activity, symptoms associated with COVID, in the need for hospitalization, hospitalization duration, and the requirement for oxygen therapy. However,CT findings compatible with COVID19, were more common in patients with damage (87% vs.33%,p=0.04) and their mean CRP levels were higher at diagnosis (65 ± 47 vs.22 ± 48 mg/l;p=0.032).

All patients received similar treatment for COVID-19 except active patients who required high dose steroids (2 with active renal, 1 with thrombocytopenia and 1 with oral ulcer, leukopenia and hypocomplementemia).The patient with thrombocytopenia also received intravenous immunoglobulin and 1 with cutaneous active disease received tocilizumab as she developed macrophage activation syndrome. Six patients (37.5%) had received rituximab (RTX) in the last 6 months before COVID. No significant difference, in terms of hospitalization and need for oxygen therapy due to COVID19 was found between patients who had received RTX vs who had not. No hypogammaglobulinemia was detected in patients who received RTX despite lower levels of IgG (998 ± 184 vs 1481± 51 mg/dl, p=0.02)

Conclusion:

Although half of the patients in our series of COVID19 infected SLE patients required hospitalization, there were no mortalities. More patients with damage (none pulmonary) displayed CT findings compatible with COVID19 and further follow up will reveal whether they will suffer from fibrotic lung disease. Patients can experience disease flares during COVID. But it is also important to consider that some manifestations such as thrombocytopenia may also be a sign of severe infection. Immunosupressive agents may not have a negative impact on the course of infection.

*the first two authors contributed equally

Disclosure of Interests:

None declared.

THU0369 EVALUATION OF DIFFERENT CLASSIFICATION CRITERIA IN SYSTEMIC SCLEROSIS IN A TURKISH COHORT: THE IMPORTANCE OF NON-SKIN MANIFESTATIONS, SEROLOGY AND CAPILLAROSCOPY

Background:

Proximal scleroderma is the major criterion in both 1980 and 2013 classification criteria for sytemic scleroris (SSc). ACR(1980) criteria included digital lesions and bibasiler fibrozis, nonetheless ACR/EULAR(2013) criteria based on a scoring system including digital lesions, telangiectasia, abnormal nailfold video-capillaroscopy(NVC), PAH, Raynaud’s and specific autoantibodies.

Objectives:

We aimed to implement both criteria in a Turkish SSc kohort to evaluate the contribution of non-skin manifestations, NVC and autoantibodies.

Methods:

A consecutive hundred and thirty-nine (125 females) SSc patients diagnosed and evaluated by the same experts (YY, MI) with relevant NVC records and at least 6 months follow-up were included into the study. Classificaiton criteria were used retrospectively using a preformed database.

Results:

Characteristics of the SSc patients were summarized in table-1. The mean age, duration of Raynaud’s and non-Raynaud symptoms were 47.1±11.9, 8.9±7.9 and 5.7±5.8 years, respectively. Diffuse and limited cutaneous disease were diagnosed in 62(44.6%) and 60(43.2%) patients respectively. Asclerodermic disease was present in 17(12.2%) patients. ANA, anti-centromere and anti-Scl70(+) positivity was 80.5%, 18.0% and 37.4%, respectively.

Twelve patients (8.6%) could not be classified as SSc by both criteria; 5 with Raynaud’s+specific antibodies (2 anti-centromere+, 2 anti-Scl70+), 4 with Raynaud’s+puffy hands+NC abnormalities, 2 with Raynaud’s+telangiectasia and a patient with Raynaud’s+sclerodactyly. Nineteen (13.7%) patients could not be classified as SSc according to ACR (1980) can be classsified according to ACR/EULAR (2013) (table-1 and -2).

The sensitivity for ACR/EULAR (2013) and ACR (1980) criteria were found to be 91,4% vs 75,5%; 98.4% vs 96.8% in diffuse cutaneous SSc, 98.3% vs 68.3% in limited cutaneous SSc and 47.1 vs 23.5% in asclerodermic SSc, respectively.

Table 1.

The sensitivity for ACR (1980) and ACR/EULAR (2013) classification criteriain SSc

ACR/EULAR (2013) +ACR/EULAR (2013)-totalACR (1980)+1080108ACR (1980)-191231total12712139Table 2.

SSc patients fulfilling ACR (1980) and/or ACR/EULAR (2013) criteria

ACR/EULAR (2013)ACR (1980)Classified n=127Not classified n=12+Prox scleroderma+87+Puffy hands294+Sclerodactyly+1121+Digital ulcers + +Pitting scars62 72+Telangiectasia862+Nailfold capillaroscopy974 Normal9 Early173 Active40 Late501+PAH12+Interstitial lung Disease +60+Raynaud’s12012+SSc- specific antibodies795

Conclusion:

The sensitivity of ACR/EULAR (2013) criteria was shown to be higher than ACR (1980) criteria in our Turkish SSc cohort with established cases. Although in diffuse cutaneous subgroup, the sensitivity was >%96 for both criteria, in limited cutaneous subgroup, the sensitivity was preserved for ACR/EULAR(2013) while apparently decreased for ACR(1980) criteria (<%70). The sensitivity for both of the two sets were lowest in the asclerodermic group. In SSc patients with limited or no skin involvement, non-skin manifestations, NVC findings and spcific serology should be carefully sought. Some of these patients could not be classified by the current criteria.

Disclosure of Interests:

None declared

THU0349 THE RELATIONSHIP BETWEEN DISEASE ACTIVITY AND SEVERITY IN SYSTEMIC SCLEROSIS: A PROSPECTIVE ANALYSIS OF 278 PATIENTS

Background:

Evaluating disease activity and severity in systemic sclerosis (SSc) is crucial to define the patients who are candidate for treatment options.

Objectives:

We aimed to investigate the relationship between disease activity and severity in SSc in a large cohort.

Methods:

This is a cross-sectional prospective analysis of 278 (253 females) patients fulfilling ACR/EULAR (2013) classification criteria for SSc. Disease activity and severity were calculated seperately for cutaneous subsets (EscSG and Medsger). The patients were grouped as inactive if EscSG score=0, mildly active if EscSG score>0<3, active if EscSG score≥3.

Results:

The mean age, duration of Raynaud’s and non-Raynaud features were 48.5±13.1, 12.1±9.8 and 8.3±7.5 years respectively. Characteristics of the SSc patients were summarized in table-1.

Ninety-three (34%) and 151(54%) patients were evaluated as having active and mildly active disease. Only 34(12%) patients had inactive disease. The patients with diffuse cutaneous involvement (dcSSc) who were active had higher modified Rodnan Skin score(mRSS) and severity scores of general, skin and joint-tendon involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin compared to those with inactive disease (table-2).The patients with limited cutaneous involvement (lcSSc) who were assessed as having active disease had higher mRSS and higher severity scores of general, skin, peripheral vascular, lung, joint-tendon and gastrointestinal involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin, lung, joint-tendon and gastrointestinal involvements compared to those with inactive disease (table-2).

Conclusion:

One third of our cohort was found to have active disease despite treatment and only 12% had inactive disease. Skin involvement and severity of different organs were shown to be higher in patients with active disease in both cutaneous subsets, together with severity of lung, peripheral vascular and gastrointestinal involvements in active lcSSc. LcSSc and dcSSc patients who had mildly active disease also had severe disease similar to those with active patients. Disease activity and severity should be assessed as separate measurements to highlight the course of the disease and may guide to the management of patients with SSc.

Disclosure of Interests:

None declared

SAT0346 THE EFFICACY AND SAFETY OF RITUXIMAB IN 27 CASES OF TREATMENT RESISTANT SYSTEMIC SCLEROSIS WITH SEVERE DISEASE ASSESSED BY ACTIVITY SCORES

Background:

Treatment options for systemic sclerosis (SSc) remain limited especially in severe skin, lung and musculoskeletal involvements. B-cell targeted therapy with anti-CD20 Rituximab (RTX), is widely available, reports from case series are encouraging as a a rescue therapy and might have an improving effect on organ involvement in SSc.

Objectives:

We aimed to retrospectively analyze the efficacy and safety of rituximab (RTX) courses in patients with severe systemic sclerosis who were refractory to standard immunosuppressive treatment.

Methods:

Twenty-seven SSc patients fulfilling ACR/EULAR classification criteria (2013) who received RTX treatment due to acive disease despite treatment with immunosuppresives were analyzed. Disease activity was evaluated by using EScSG/EUSTAR activity scores prior to and after RTX treatment. Disease severity was also assessed at baseline by Medsger’s index.

Results:

The demographics and characteristics of SSc patients were as follows: the median age of 50 (30-70), duration of Raynaud’s 10 (3-26) and non-Raynaud symptom 8.5 (3-18) years and summarised in table 1. RTX was given as a single cycle (2 infusions of 1000 mg) in 12 cases, 2 cyles in 5 cases, ≥3 cyles in 10 cases. DMARDs were prescribed in 19 (73%) patients (14 MMF, 5 MTX) concomitantly with RTX. The main RTX indications were skin and lung involvement (n=9), skin and arthritis (n=6), skin(n=5), lung (n=3), myositis (n=2), cardiac involvement (n=1) and digital vasculopathy (n=1). Medsger severity score was 7.39±3.091(3-13) at baseline.

Table 1.

Prevelance of Characteristics of SSc Patients

n(%)female/male25 /2diffuse/limited cutaneous SSc22 (81.5) / 5 (19,2)Clinical Characteristicssynovitis / flexion contractures12(44,4) / 10 (37,1)tendon friction rubs / myositis7 (26,9) / 4 (15,4)renal crisis1 (3,8)GI involvement19 (69,2)lung involvement16 (61,5)SerologyANA23 (85,2)Anti-Scl70 / Anti-sentromer16(61,5) / 1(3,8)Anti-Ro6 (22,2)Previous ImmunosuppressivesCYC / MMFAZA / MTX Low dose steroids19 (73,1) / 19 (73,1) 12 (46,2) / 16 (61,5) 27 (100)

Disease activity and severity scores prior to and after RTX were summarised table 2. Disease activity scores were improved after RTX in patients who had a median follow-up period of 1 year (0,5-5 years). After RTX treatment, according to EscSG /EUSTAR scores 13 (%46.2) and 10 (%34.6) patients out of 26 were assessed as inactive.

Table 2.

Disease activity scores prior to and after RTX treatment

Prior to RTX (n=26)After RTX (n=18)median Δ Change (n=18)EscSG activity score4,89±1,82 (2,0-9,0)2,37±1,10 (0,50-4,50)-2,00 (P<0,001)EUSTAR activity score4,57±2,68(1,0-10,0)2,30±2,15 (0,0-7,25)-2,00 (P=0,002)

There were severe infecions in 4 patients (Pneumonia in 2, infected digital ulcers in 2) and an episode of sinusitis in one during treatment period. One patient was deceased because of pneumonia and sepsis after the first cycle of RTX.

Conclusion:

In our SSc cohort, RTX treatment was used in severe patients, who had predominantly diffuse cutaneous disease with lung and joint involvements, severe vasculopathy and anti-Scl-70 positivity. Concomitant DMARDs were used in three-forth of the patients in addition to RTX cycles. Disease activity scores that assessed retrospectively were shown to be improved after RTX and 37-48% of the cases were assessed as inactive by using activity scores. Serious infections like pneumonia and infected digital ulcers were observed in 14,8% of cases during the follow-up. The addition of RTX treatment can be effective in selected patients with active disease despite immunosuppressive therapy.

Disclosure of Interests:

None declared