Damage in the Multiethnic Malaysian Systemic Lupus Erythematosus (SLE) Cohort: Comparison with Other Cohorts Worldwide

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease and despite the improvement in the survival in the past few decades, the morbidity due to disease damage remains significant. The objectives of this study were to investigate the disease damagepattern and determine the associated factors of damage in the multi-ethnic Malaysian SLE patients. We consecutively 424SLE patients who attended a consistent follow-up at the National University of Malaysia Medical Centre and Putrajaya Hospital were recruited. Disease damage was assessed using the SLICC/ACR (Systemic Lupus International Collaborating Clinics/American College of Rheumatology) Damage Index (SDI) scores. Information on their demographics and disease characteristics were obtained from the clinical record. Univariate analysis was performed and the best model of independent predictors of disease damage was determined by multivariate logistic regression analysis. A total of 182 patients (42.9%) had disease damage (SDI ≥1). A significantly higher number of Indian patients had disease/organ damage and they predominantly developed steroid-induced diabetes mellitus (SDM). Patients with corticosteroid-induced osteoporosis (CIOP) were more likely to be Malayswhile majority of patients who developed malignancy were Chinese (p<0.05). In the univariate and multivariate analyses, disease damage was significantly associated with age, Indian ethnicity, lower mean cumulative C3 level, neuropsychiatry lupus (NPSLE), and antiphospholipid syndrome (APLS). Patients who had ever and early treatment with hydroxychloroquine(HCQ)were less likely to develop disease damage while more patients who had received oral prednisolone ≥1mg/kg daily over 2 weeks had disease damage (p<0.05). In conclusion, there were inter-ethnic differences in the damage pattern and risks among SLE patients.

The Effects of Annatto Tocotrienol Supplementation on Cartilage and Subchondral Bone in an Animal Model of Osteoarthritis Induced by Monosodium Iodoacetate

Osteoarthritis is a degenerative joint disease which primarily affects the articular cartilage and subchondral bones. Since there is an underlying localized inflammatory component in the pathogenesis of osteoarthritis, compounds like tocotrienol with anti-inflammatory properties may be able to retard its progression. This study aimed to determine the effects of oral tocotrienol supplementation on the articular cartilage and subchondral bone in a rat model of osteoarthritis induced by monosodium iodoacetate (MIA). Thirty male Sprague-Dawley rats (three-month-old) were randomized into five groups. Four groups were induced with osteoarthritis (single injection of MIA at week 0) and another served as the sham group. Three of the four groups with osteoarthritis were supplemented with annatto tocotrienol at 50, 100 and 150 mg/kg/day orally for five weeks. At week 5, all rats were sacrificed, and their tibial-femoral joints were harvested for analysis. The results indicated that the groups which received annatto tocotrienol at 100 and 150 mg/kg/day had lower histological scores and cartilage remodeling markers. Annatto tocotrienol at 150 mg/kg/day significantly lowered the osteocalcin levels and osteoclast surface of subchondral bone. In conclusion, annatto tocotrienol may potentially retard the progression of osteoarthritis. Future studies to confirm its mechanism of joint protection should be performed.

Burden of Systemic Lupus Erythematosus on Work Productivity and Daily Living Activity: A Cross-Sectional Study Among Malaysian Multi-Ethnic Cohort

Objectives

This study aims to assess the self-reported work productivity and activity daily living (ADL) impairment among Malaysian patients with systemic lupus erythematosus (SLE) and to examine their associated factors.

Patients and methods

This cross-sectional study included 167 SLE patients (21 males, 146 females; mean age 38.2±9.8 years; range, 20 to 60 years) recruited from the outpatient Rheumatology and Nephrology clinics. Face-to-face interviews were conducted to record patients' socio- demographics (age, sex, ethnicity, marital status, and occupation) and SLE disease characteristics (system involvement, age onset, and presence of organ damage). Disease activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K). Short form 36 (SF-36) was used to determine health-related quality of life (HRQoL) while Work Productivity and Activity Impairment (WPAI) questionnaire was used to assess the four domains of absenteeism, presenteeism, overall work productivity, and non-work related ADL impairment. Univariate analyses and multivariable regression analysis examined the association of demographic variables, SLE disease characteristics, and activity with reduced HRQoL and WPAI scores.

Results

The majority of the patients were Malays (59.3%), followed by Chinese (34.7%) and Indian (3.6%) patients. More than two-thirds of the patients reported some degree of impairment in their work productivity and ADL due to the disease. The absenteeism rate was 10.4% in the past one week and their indirect costs were 2,875.17 Malaysian ringgits (US $701.22) in the past seven days. Significant predictors of higher work productivity and ADL impairment scores were higher disease activity, more frequent SLE flares, lupus nephritis, and hematological involvement of SLE. Patients with higher work productivity and ADL impairment scores were also strongly associated with poor QoL. No ethnic disparities of work productivity and ADL impairment were found.

Conclusion

Systemic lupus erythematosus significantly affected the overall productivity in work and non-work related activity in our Malaysian multi-ethnic cohort and both impairments were significantly associated with poor QoL.

Serum and urine interleukin-17A levels as biomarkers of disease activity in systemic lupus erythematosus

OBJECTIVES

This study examined the correlations of both serum and urine interleukin-17A (IL-17A) levels with disease activity in systemic lupus erythematosus (SLE). This study was also aimed at determining their sensitivity and specificity as biomarkers of disease activity in SLE.

METHODS

A cross-sectional study was performed involving SLE patients (n = 120 patients) from Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Serum and urinary IL-17A levels were determined by immunoassay while disease activity was assessed using Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K) and British Isles Lupus Assessment Group's 2004 index (BILAG 2004) scores. The correlations between serum and urinary IL-17A levels with total SLEDAI-2K and BILAG 2004 scores were determined using bivariate correlation analyses. Receiver operating characteristic curves were calculated to determine their sensitivity and specificity as disease activity biomarkers.

RESULTS

Both serum and urinary IL-17A levels correlated with total scores of BILAG 2004, BILAG renal, BILAG mucocutaneous, and SLEDAI-2K (P < 0.05). Urine IL-17A levels correlated positively with urine protein : creatinine index while serum IL-17 level correlated with the BILAG hematology score (all P < 0.05). The area under curve of serum IL-17A and urine IL-17A with BILAG and SLEDAI scores were low (<0.75).

CONCLUSION

Despite positive correlations between serum and urine IL-17A with SLE disease activity, both were neither sensitive nor specific as biomarkers to predict active disease. Hence, IL-17 measurement has no role in SLE disease activity assessments and future studies are needed to search for other reliable activity biomarkers.

Chronic necrotizing pulmonary aspergillosis presenting as bilateral pleural effusion: a case report

INTRODUCTION

Chronic necrotizing pulmonary aspergillosis is an uncommon subacute form of Aspergillus infection. It typically occurs in immunocompromised individuals and in those with underlying lung disease. This interesting case highlights the occurrence of this entity of aspergillosis in an immunocompetent middle-aged woman with atypical radiological findings. To the best of our knowledge this is the first case report of chronic necrotizing pulmonary aspergillosis presenting with pleural effusion.

CASE PRESENTATION

Our patient was a 64-year-old Malay woman with a background history of epilepsy but no other comorbidities. She was a lifelong non-smoker. She presented to our facility with a six-month history of productive cough and three episodes of hemoptysis. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation. Bronchoscopy revealed a white-coated endobronchial tree and bronchoalveolar lavage culture grew Aspergillus niger. A diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the clinical presentation and microbiological results. She responded well to treatment with oral itraconazole.

CONCLUSIONS

The radiological findings in chronic necrotizing pulmonary aspergillosis can be very diverse. This case illustrates that this condition can be a rare cause of bilateral pleural effusion.

Risk factors for symptomatic Avascular Necrosis (AVN) in a multi-ethnic Systemic Lupus Erythematosus (SLE) cohort

Avascular necrosis of bone (AVN) is increasingly being recognized as a complication of SLE and causes significant disability due to pain and mobility limitations. We studied the prevalence and factors associated with avascular necrosis (AVN) in a multiethnic SLE cohort. SLE patients who visited the outpatient clinic from October 2017 to April 2019 were considered eligible. Their medical records were reviewed to identify patients who developed symptomatic AVN, as confirmed by either magnetic resonance imaging or plain radiography. Subsequently, their SLE disease characteristics and treatment were compared with the characteristics of patients who did not have AVN. Multivariable logistic regression analyses were performed to determine the independent factors associated with AVN among the multiethnic SLE cohort. A total of 390 patients were recruited, and the majority of them were females (92.6%); the patients were predominantly of Malay ethnicity (59.5%), followed by Chinese (35.9%) and Indian (4.6%). The prevalence of symptomatic AVN was 14.1%, and the mean age of AVN diagnosis was 37.6 ± 14.4 years. Both univariate and multivariable logistic regression analyses revealed that a longer disease duration, high LDL-C (low density lipoprotein cholesterol), positive anti-cardiolipin (aCL) IgG and anti-dsDNA results, a history of an oral prednisolone dose of more than 30 mg daily for at least 4 weeks and osteoporotic fractures were significantly associated with AVN. On the other hand, hydroxychloroquin (HCQ), mycophenolate mofetil (MMF) and bisphosphonate use were associated with a lower risk of AVN. No associations with ethnicity were found. In conclusion, several modifiable risk factors were found to be associated with AVN, and these factors may be used to identify patients who are at high risk of developing such complications. The potential protective effects of HCQ, MMF and bisphosphonates warrant additional studies.

An increasingly notorious mimicker of testicular tumours; crossing borders

Data from the WHO state that up to 85% of cases of human schistosomiasis are from Africa. The common sites of this parasitic infection are the intestine and bladder. Testicular schistosomiasis is extremely rare but the number of reported cases worldwide has doubled over the past decade. The authors report a case of testicular schistosomiasis of a Myanmar immigrant in Malaysia who presented with a 6-month history of progressively enlarging left testicular swelling. His biochemical markers and cultures were not suggestive of an ongoing infection. Hence, a testicular malignancy was strongly suspected, for which, he underwent a left orchidectomy. Our clinical suspicion was proven wrong when the histopathology of the removed left testis revealed schistosomal eggs with granulamatous tissue formation. Subsequently, the patient was treated with praziquantel.

Etanercept in the treatment of recalcitrant enteropathic arthritis: a case report

Introduction

Enteropathic arthritis is one of the recognized extraintestinal manifestations of inflammatory bowel disease and affects up to 25% of patients. The treatment options for refractory disease were rather limited and ineffective until the arrival of biologic therapy in the last few years. The use of etanercept was unique for this disease.

Case presentation

In this case report, a 58-year-old Malay woman with a 17-year history of ulcerative colitis had persistent left knee effusion and synovitis for seven years, despite remission of the primary disease. She had had multiple courses of systemic and intra-articular steroid that caused significant systemic side effects such as impaired fasting glucose, hypertension, cataract, and weight gain. She also had a total left knee replacement for secondary osteoarthritis. But the left knee synovitis and effusion recurred a month after the total knee replacement, and she was subjected to a total synovectomy the following year. In view of failure of remission despite multiple immunosuppressants (100 mg of azathioprine daily, 1 g of sulfasalazine twice a day, 10 mg of prednisolone daily, and 10 mg of methotrexate weekly), 25 mg of subcutaneous etanercept twice weekly was started. After 5 weeks of treatment, complete resolution of left knee effusion and normalization of the inflammatory markers were shown. This continued up to 12 months of follow-up while our patient was on etanercept and 10 mg of methotrexate weekly. No relapse or serious side effects were noted.

Conclusions

This case demonstrates the efficacy of etanercept in recalcitrant enteropathic arthritis with no relapse of the underlying colitis while on treatment. The usage of this tumor necrosis factor inhibitor was unique in this case of rheumatology and gastroenterology.

AB0155 COMPARATIVE ANALYSES OF SEROLOGICAL BIOMARKERS AND DISEASE CHARACTERISTICS BETWEEN ELDERLY ONSET RHEUMATOID ARTHRITIS (EORA) AND YOUNGER ONSET RHEUMATOID ARTHRITIS (YORA)

Background:

Several studies have reported differences in disease characteristics between elderly onset RA (EORA: age of onset > 60 years) and younger-onset RA (YORA). However, the findings across the studies have been rather inconsistent owing partially to the genetic variation across the populations studied. While a few studies have looked into the clinical aspects of EORA, there is a profound lack of comparative data on serological findings between EORA and YORA. Seropositive RA is known to be associated with more aggressive disease and the titres of the autoantibodies may predict the disease activity and the severity of radiographic progression.

Objectives:

The main aim of this study was to compare the levels of the autoantibodies namely anti–CCP (cyclic citrulinated peptide), IgA, IgM, IgG rheumatoid factors(RF) and disease characteristics between the EORA and YORA groups.

Methods:

We consecutively recruited a total of 151 female RA patients who were tested for IgA RF, IgG RF, IgM RF and anti CCP antibodies. Participants were aged above 18 years and met the 2010 ACR/EULAR RA criteria. Data on the disease characteristics (age at onset, disease activity at onset, disease duration and medications)were obtained by reviewing the medical records of the subjects. Subjects were divided into 2 groups i.e EORA and YORA based on age at onset of RA. All subjects were assessed for the severity of radiographic joint damage and functional disability based on Modified Sharp Score (MSS) and Health-assessment questionnaire-disability index (HAQ- DI), respectively. The EULAR response criteria was used to determine the subjects’ response to disease-modifying anti-rheumatic drugs.

Results:

The EORA group had 69 patients whereas the YORA group had 82 patients. The mean anti-CCP and IgA RF levels were significantly higher in the YORA group with p values of 0.002 and 0.035, respectively. The YORA group had significantly more severe disease at onset (p value for DAS 28 at onset was 0.009) with worse radiographic joint damage (p value for MSS was 0.006). In parallel with these findings, the YORA group had significantly higher ESR and CRP at onset with higher frequency of subjects requiring advanced therapies. The differences in frequency of RF positivity, disease duration, number of DMARDs, prednisolone dose and HAQ-Di scores between the groups did not reach statistical significance.

Conclusion:

EORA is characterized by lower levels of anti-CCP and IgA autoantibodies with less aggressive disease as compared to YORA.

References:

[1]Calvo-Alen J, Corrales A, et al.Clinical rheumatology 2005;24:485-9.

[2]Huscher D, Sengler C, Ochs W, et al. Clinical and experimental rheumatology 2013;31:256-62.

[3]Mueller RB, Kaegi T, et al. Rheumatology 2014;53:671-7.

Table 1.

Comparison of disease characteristics between EORA and YORA

ParameterEORA (n=69)YORA(n=82)p valueAge (years)*67.19± 2.4931.93± 5.10<0.050Disease duration (years)*8.06±5.048.70± 3.630.365DAS28 at onset*3.29± 1.373.96± 1.680.009RF positive at onset47 (68.11)62 (75.61)0.306Anti CCP titre*84.52±117.97151.14±138.020.002IgA RF titre*24.15±39.5443.14±64.820.035IgM RF titre*68.58±97.6572.74±93.280.789IgG RF titre*64.36±66.0170.88±69.580.558ESR at onset(mm/hr)*54.20± 20.5067.04± 23.600.001CRP at onset(mmol/L)*1.33± 1.373.79± 8.110.019No. of DMARDS 145 (65.21)41 (50.00) 216 (23.19)32 (39.02)0.106 38 (11.59)9 (10.98)On biologics & tsDMARD12 (17.39)35 (42.68)0.008Prednisolone dose (mg)*2.83 ± 3.32 2.77 ± 3.020.920Treatment Response Good50 (72.46)54 (65.86)0.487 Moderate15 (21.74)19 (23.17) None4 (5.80)9 (10.98)MSS*10.04±12.7917.49±19.040.006HAQ-DI*1.47±0.871.58±0.710.397

Data presented as either counts (percentages) or mean ± SD*

Disclosure of Interests:

None declared

Dermatomyositis masquerading musculoskeletal tuberculosis

Dermatomyositis is a rare rheumatic disease which predominantly affects the muscles and skin requiring a protracted course of immunosuppressants which may predispose the patients to opportunistic infections. A 49-year-old lady was diagnosed to have dermatomyositis in August 2010 based on history, significantly raised creatine kinase level and muscle biopsy findings. She had recurrent admissions due to fever, myalgia and muscle weakness. She had spiking temperature despite high dose steroids, broad-spectrum antibiotics and antifungal agents. This prompted extensive investigation which leads us to the additional diagnosis of disseminated tuberculosis involving the lungs, muscles and bones. This case demonstrates the challenge in controlling the disease activity of dermatomyositis with immunosuppressants in the setting of disseminated tuberculosis.

POS0723 HERPES ZOSTER IN A MULTI-ETHNIC SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) COHORT: CLINICAL FEATURES AND RISK FACTORS

Background:

Systemic Lupus Erythematosus (SLE) patients are at risk of Herpes Zoster (HZ) infection due to the underlying immunosuppressed state. The reported incidence of HZ in SLE is 6 to 10-times higher than the general population.

Objectives:

To determine the clinical characteristics of SLE patients who develop Herpes Zoster (HZ) infection and their associated risk factors.

Methods:

Medical records review was performed on consecutive SLE patients in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from 2018 until 2019. Previous history of HZ and their demographic characteristics, clinical and medications used at the time of infection were recorded. Univariate and multivariate analyses were performed to compare the clinical and treatment characteristics between SLE patients with history of HZ and patients who had never had experienced HZ.

Results:

A total of 229 patients with predominantly Malay patients (n=123, 53.7%), followed by Chinese (n=90, 39.3%) and others (n=16, 7.0%) were included. A total of 37 patients had history of HZ (16.2%). Their mean age during HZ episode was 34.4 ± 13.8 years and their SLE disease duration was 68.7 ±57.1 months. More than half of them (n=21, 56.8%) developed HZ when the SLE disease was active with the mean dose of prednisolone at the time of infection was 20.7 ± 9.2 mg daily. A total of 21 HZ patients (56.8%) had ever received cyclophosphamide with the median interval of the last infusion was 6 (0.2-84) months. Almost half of the HZ patients (n=18, 48.6%) developed the infection while on cyclosporine A. Meanwhile, 4 (10.8%) were on azathioprine and mycophenolate mofetil respectively. Chinese patients tend to have HZ as compared to other ethnics (27% vs 41.7%), p=0.07. HZ occurred in a higher proportion among male patients (29%) as compared to female patients (14.1%), p=0.05. The use of azathioprine (10.8% vs 55.2%, p<0.01) and mycophenolate mofetil (10.8% vs 31.8%, p=0.009) were less associated with HZ. On the other hand, the use of cyclosporine A (48.6% vs 32.3%, p=0.05) and prednisolone ≥ 60mg daily (44.4% vs 28%, p=0.04) were associated with HZ. Higher HZ patients had hematological manifestation (81.1% vs 62.5%, p=0.04) and positive lupus anticoagulant (LA), 32.4% vs 14.6%, p=0.02. A forward logistic regression which included all factors with p<0.1 in the univariate analyses revealed that the use of prednisolone ≥ 60mg daily and hematological manifestation were the independent predictors of HZ with OR= 2.28 (95% C.I = 1.01-5.17), p=0.049 and OR= 2.78 (95% C.I = 1.09-7.04), p=0.03 respectively. The use of azathioprine was associated with a lower risk of HZ with OR 0.08 (95% C. I= 0.03-0.25), p=<0.01.

Conclusion:

Our study demonstrated the possible influence of male gender, Chinese ethnicity and disease characteristics such as hematological manifestation and lupus anticoagulant positivity with the occurrence of HZ. In addition, the use high dose oral prednisolone ≥ 60mg daily was the independent predictor of HZ while on the other hand, the use of azathioprine was associated with a lower risk of developing HZ as compared to other immunosuppressive agents. Further larger studies are needed to confirm these associations.

References:

[1]Chen D, Li H, Xie J, Zhan Z, Liang L, Yang X. Herpes zoster in patients with systemic lupus erythematosus: Clinical features, complications and risk factors. Exp Ther Med. 2017;14(6):6222-6228.

Disclosure of Interests:

None declared

THU0283 DISTINCT CLINICAL FEATURES OF LATE–ONSET SYSTEMIC LUPUS ERYTHEMATOSUS AMONG MALAYSIAN MULTI-ETHNIC COHORT

Background:

Systemic Lupus Erythematosus (SLE) commonly affects young women in their reproductive age group. However, there is an increase prevalence of late-onset SLE, parallel to the higher life expectancies among general populations worldwide. It has been reported that up to 25% SLE populations have a later onset of disease and their disease expression and course may be different.

Objectives:

To determine the clinical features and outcomes of late-onset SLE patients in a multi-ethnic Malaysian cohort.

Methods:

Medical records of SLE patients who attended regular follow-up clinics in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from 2011 until June 2019 were reviewed. Late-onset SLE was defined as the onset of SLE symptoms or diagnosis after the age of 50 years old. Information on their socio-demographics and disease characteristics were obtained from the clinical records. Disease damage was assessed using the SLICC/ACR (Systemic Lupus International Collaborating Clinics/American College of Rheumatology) Damage Index (SDI) scores. The disease characteristics and autoantibody profiles were compared between late-onset and younger onset patients. Damage accrual at disease onset and at 5 years was obtained and compared between the two groups.

Results:

A total of 429 patients were included and majority of them were Malays (n= 225, 52.4%) followed by Chinese (n=180, 42), Indian (n=21, 4.9%) and others (n=3,0.7%). This multi-ethnic SLE cohort was consisted of predominantyly female patients (n=372,86.7%) with disease duration of 9.9 years ± 6.8 years. A total of 13.8% (n=59) had late onset SLE with mean onset of disease at 58.1 ± 6.3 years while younger group was 27.2 ± 9.4 years. The commonest system involvement among the late-onset group was haematological manifestation (69.5%).Compared to the younger-onset SLE, late-onset SLE occurred significantly higher among the Chinese (66.1%) as compared to Malay (32.3%), Indians and other ethnics (1.7%), p<0.01. Patients with late-onset SLE also had significantly less musculoskeletal (37.3% vs 62.4%) and renal (23.7% vs 71.1%), p<0.001 and tend to have less muco-cutanoues manifestations (28.8 vs 42.4%, p=0.06). Meanwhile, pulmonary involvement was more common among the late onset SLE patients (11.9% vs 0.8%, p<0.001). Extractable nuclear antigen (ENA) results were available in 197 patients and patients with late-onset SLE had significantly higher rate of anti-RO positive (63% vs 3.9%), p=0.01. Otherwise, no significant difference in the other autoantibodies expressions including anti-La, anti-Sm, anti-RNP, anti-ribosomal P and anti-phospholipid antibodies. Patients with late-onset SLE tend to have more damage accrual at 5 years as compared to the younger age group (p=0.07). The mortality in the late onset group was 13.6% (n=8) as compared to 2.7% (n=10) in the younger age group, p=0.01. Majority of the cause of death in the later onset SLE was infection (87.5%) while in the younger age group was infection and active disease (90%).

Conclusion:

Late onset SLE occurs more commonly among Chinese ethnics in Malaysia and Malaysian SLE patients with late onset of the disease have distinct clinical manifestations. Damage accrual at 5 years tend to be higher in the late-onset group and the mortality is significantly higher with the major cause of death is infection. The different disease expression and outcome in late onset SLE suggest different factors in influencing the disease course and hence further studies including their genetic profiles are warranted.

References:

[1]Paula I. Burgos; Graciela S. Alarcón. Late-onset Lupus: Facts and Fiction. Future Rheumatol. 2008;3(4):351-356.

[2]S Stefanidou, C Gerodimos, A Benos et al. Clinical expression and course in patients with late onset systemic lupus erythematosus. Hippokratia. 2013; 17(2): 153–156.

Acknowledgments:

This research was supported by the “Fundamental Research Grant Scheme (FRGS/1/2018/SKK02/UKM/03/1)” by Ministry of Education Malaysia

Disclosure of Interests:

Syahrul Sazliyana Shaharir: None declared, Mohd Shahrir Mohamed Said: None declared, Sakthiswary Rajalingham Speakers bureau: Pfizer (500USD), Hazlina Mahadzir: None declared, Ruslinda Mustafar: None declared, Asrul Abdul Wahab: None declared

Self-Reported Delayed Adverse Events and Flare Following COVID-19 Vaccination Among Patients With Autoimmune Rheumatic Disease (AIRD) in Malaysia: Results From the COVAD-2 Study

OBJECTIVES

To determine the prevalence of self-reported delayed adverse events (DAEs), major AEs, and flares following COVID-19 vaccinations among patients with autoimmune rheumatic diseases (AIRDs) in Malaysia.

METHODOLOGY

An electronically validated survey from the COVID-19 vaccination in autoimmune diseases (COVAD) study group was distributed in July 2021 to patients with autoimmune diseases and healthy controls (HCs). The survey collected data on DAEs (any AE that persisted or occurred after 7 days of vaccination), any early or delayed major adverse events (MAEs), and flares following COVID-19 vaccination. Generalized estimating equation (GEE) models were performed to determine the factors associated with repeated events of DAEs, MAEs, and flares.

RESULTS

A total of 556 vaccines were administered to 204 subjects (150 AIRDs and 54 HCs), with 72.1% completing 3 doses. In multivariate GEE analysis, there was a greater frequency of minor DAEs among AIRDs versus HCs (OR 5.65, p = 0.052). The occurrence of MAEs was higher in AIRDs versus HCs (4.9% vs. 1.3%, p = 0.052), but it was no longer significant in the GEE model. In the AIRDs group, the BNT162b2 vaccine increased the risk for minor DAEs (OR4.68, p = 0.02) while patients with autoimmune multimorbidity showed a greater risk for MAEs (OR 8.25, p = 0.007). The rate of flare was 10.6% and multivariate GEE analysis revealed that The rate of flare was 10.6% and multivariate GEE analysis revealed that systemic lupus erythematosus (SLE) (OR0.31, p = 0.03) and hydroxychloroquine (HCQ) (OR 0.16, p < 0.001) were protective against flare.

CONCLUSION

The rates of minor DAEs, major AEs, and flares were comparable with other reported studies. Different types of vaccines, underlying AIRDs, and treatments may influence the symptoms of AEs and flares postvaccination against COVID-19.

POS0394 VALIDATION OF THE SLE SUSCEPTIBLE GENE LOCI IN THE MULTI-ETHNIC MALAYSIAN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) COHORT AND THEIR ASSOCIATIONS WITH CLINICAL MANIFESTATION

Background

Systemic Lupus erythematous (SLE) is an autoimmune disease with a wide spectrum of clinical manifestations. Asian patients including Malaysia tend to have more severe disease with renal involvement. The differences could be due to the interactions between genetic and environmental factors. Thus, identifying the genetic associations from diverse populations provides a better understanding on the genetic architecture of this heterogeneous disease.

Objectives

The primary objective of this study was to validate the previously described SLE susceptibility gene loci among other population in the multi-ethnic Malaysian SLE patients. The secondary objective was to determine the association between the gene loci with organ-specific involvement across different Malaysian ethnicities.

Methods

This was a case-control study involving the recruitment of SLE patients who attended the outpatient clinic in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from July 2019 until March 2021. Their medical records were reviewed to record the socio-demographic characteristics and SLE clinical manifestations. The SLE susceptible gene loci from the NHGRI-EBI Catalog of human genome-wide association studies were reviewed. The gene loci with p values less than 5x10-8 tested in a total sample size of at least 1000 individuals were included in the genotyping study in our SLE patients. Healthy controls with frequency matching by gender and ethnicity-matched were also recruited in this study. Their peripheral blood samples were genotyped using the Agena MassARRAY system (Agena Bioscience). The genotype frequencies of susceptibility loci in all patients and controls were tested for Hardy–Weinberg equilibrium. Associations between phenotype and genotype were performed by logistic regression analysis.

Results

A total of 202 SLE patients and 206 healthy controls were recruited. The SLE cohort consisted of predominant Malay ethnicity (n=126,62.6%) followed by Malaysian Chinese (n=69, 34.2%) and Indian (n=7, 3.5%). After quality control and Hardy–Weinberg equilibrium test, a total of 27 candidate SNPs were genotyped in our study population. Meta-analysis revealed 5 gene loci at SNP rs4544377 (RNU6-546P), rs4917014 (IKZF1), rs1878186 (SLC12A1), rs4728142 (IRF5) and rs5029937 (TNFAIP3) were associated with SLE in Malaysian population (all p value <0.05). In Malay group, rs4544377 (RNU6-546P) and rs4728142 (IRF5) were found to be associated with SLE with adjusted OR 0.42 (95% CI: 0.24-0.74), p=0.002 and OR 3.08 (95% CI: 1.71-5.54), p=0.000169, respectively. In Malaysian Chinese group, rs4917014 (IKZF1) was found to be associated with SLE with OR 0.45 (95% CI: 0.23-0.86), p=0.016. Among Malay patients, rs1878186 (SLC12A1) was found to be associated with skin rash with OR 2.01 (95% CI: 1.20-3.35), p=0.008 while rs4544377 (RNU6-546P) and rs4917014 (IKZF1) were associated with lupus nephritis, with OR 0.48 (95% CI: 0.24-0.96), p=0.039 and OR 3.29 (95% CI: 1.18-9.20), p=0.023. In Malaysian Chinese patients, rs4544377 (RNU6-546P) was associated with muco-cutaneous manifestation with OR 2.82 (95% CI: 1.15-6.92), p=0.023 while rs4728142 (IRF5) was associated with haematological manifestation with OR 5.61 (95% CI: 1.69-18.60), p=0.005.

Conclusion

Our exploratory study demonstrates the associations of the established SLE genes in Malaysian SLE populations. There are variations in the SLE susceptible gene loci with clinical manifestations of SLE between Malay and Malaysian Chinese populations.

References

[1]J. E. Molineros, K. H. Chua, C. Sun, L. H. Lian, P. Motghare, X. Kim-Howard, et al. Evaluation of SLE Susceptibility Genes in Malaysians. Autoimmune Diseases 2014 Vol. 2014 Pages 305436

Acknowledgements

This study received funding from the Fundamental Research Grant Scheme (FRGS) of the Ministry of Education, Malaysia (FRGS/1/2018/SKK02/UKM/03/1)

Disclosure of Interests

None declared.

FRI0073 SEROLOGICAL PREDICTORS OF THE SEVERITY OF RHEUMATOID ARTHRITIS RELATED INTERSTITIAL LUNG DISEASE

Background:

The most common extra-articular manifestation of rheumatoid arthritis(RA) is interstitial lung disease (ILD). Although pulmonary manifestations in RA encompass the main airway, parenchyma, vasculature and pleura, ILD in particular, is associated with reduced survival. Up to 10% of RA patients suffer from clinically significant ILD while a substantial proportion have abnormal CT chest findings despite being asymptomatic.There are various biochemical and serological markers to predict the severity of the joints in RA. However, the clinical and laboratory determinants of RA related ILD (RA-ILD) are not well defined owing to the paucity of research data in this regard.

Objectives:

The main objective of this study is to determine the correlation between the rheumatoid factor (RF) serotypes and the severity of RA-ILD based on computer tomography (CT) findings.

Methods:

We recruited a total of 100 RA patients who were tested for IgA RF, IgG RF and IgM RF and had high resolution CT chest performed. Participants were aged above 18 years, met the 2010 ACR/EULAR RA criteria, had RA for more than 6 months, were non-smokers, not pregnant and had no known chronic lung disease or lung malignancy based on their medical records. Seventy-two patients had ILD changes on HRCT of the chest and were included in this study. The CT images were scored based on a scoring system proposed by Kazerooni et al. Ground glass opacities represented the alveolar findings whereas honeycombing and septal thickening were the interstitial findings. The ground glass and fibrosis scores were on a scale of 0-5, with higher scores for greater involvement of the lobes. For each subject, the maximum ground glass and fibrosis scores were 25, respectively.

Results:

The frequency of RF positivity was comparable across the 3 serotypes (83.33-84.72%). The correlation between the clinical variables and the CT scores are listed in Table 1.We found that the the CT scores for ground glass showed significant positive correlation with disease duration (p=0.047)and IgA RF levels (p<0.050)whereas the fibrosis scores had significant relationship with multiple clinical covariates i.e age (p=0.004), disease duration (p=0.042), IgA RF levels (p<0.050), IgG RF levels (p=0.041) and anti-CCP levels (p=0.006). On multivariate analysis, only IgA RF levels remained significantly (p<0.05, standardized beta coefficient =0.604) associated with the ground glass scores. As for the fibrosis scores, IgA RF levels and age were independent predictors based on multivariate analysis after adjusting for confounders, with p scores of <0.05 and 0.02, respectively.

Table 1.

Correlation of CT scores with clinical covariates and antibodies

ParametersGround glassFibrosisrp valuerp valueAge0.2290.0530.3340.004Disease duration0.2350.0470.2400.042Total MSS0.0580.6280.2240.145Cumulative Methotrexate dose0.0390.7480.0980.413Ig A0.608<0.050.576<0.05Ig M0.0530.6600.0190.873Ig G0.1830.1240.2410.041Anti CCP0.1170.3280.3190.006

Conclusion:

The IgA RF was the only serotype which was independently associated with the severity of RA-ILD.

References:

[1]Bongartz, T., Nannini, C., Medina-Velasquez, Y. F., Achenbach, S. J., Crowson, C. S., Ryu,et al. (2010). Incidence and mortality of interstitial lung disease in rheumatoid arthritis: a population-based study. Arthritis and rheumatism, 62(6), 1583-1591.

[2]Dawson, J. K., Fewins, H. E., Desmond, J., Lynch, M. P., & Graham, D. R. (2001). Fibrosing alveolitis in patients with rheumatoid arthritis as assessed by high resolution computed tomography, chest radiography, and pulmonary function tests. Thorax, 56(8), 622-627.

[3]Kazerooni, E. A., Martinez, F. J., Flint, A., Jamadar, D. A., Gross, B. H.,et al. (1997). Thin-section CT obtained at 10-mm increments versus limited three-level thin-section CT for idiopathic pulmonary fibrosis: correlation with pathologic scoring. AJR Am J Roentgenol, 169(4), 977-983.

[4]van der Helm-van Mil, A. H., & Huizinga, T. W. (2012). The 2010 ACR/EULAR criteria for rheumatoid arthritis: do they affect the classification or diagnosis of rheumatoid arthritis? Annals of the rheumatic diseases, 71(10), 1596-1598.

Disclosure of Interests:

Sakthiswary Rajalingham Speakers bureau: Pfizer (500USD), Syahrul Sazliyana Shaharir: None declared, Radhika Sridharan: None declared

Rheumatoid arthritis: refractory to infliximab, a tumor necrosis factor inhibitor

Rheumatoid arthritis is one of the commonest autoimmune diseases. It is a chronic, progressive, systemic inflammatory disorder affecting the synovial joints and typically producing symmetrical arthritis. If left untreated, it leads to joint destruction and thus deformity and disability.In the recent years, advances in molecular biology have led to a variety of new treatment approaches to rheumatoid arthritis and other systemic inflammatory diseases associated with autoimmunity. Anti tumor necrosis factor (TNF) agents are emerging in the frontline management of rheumatoid arthritis (RA) in the current era of biological treatment. We presented a 46-year-old Chinese female with a history of seropositive RA for the past 22 years refractory and intolerant to multiple medications including sulphasalazine (SSZ), leflunomide, hydroxychloroquine (HCQ) and methotrexate (MTX), thus infliximab, a tumor necrosis factor (TNF) inhibitor was initiated. However, despite receiving 6 cycles of infliximab therapy, she still complained of persistent disabled multiple joint pain and swelling. This report will discuss about rheumatoid arthritis, which is refractory to infliximab (a TNF inhibitor) and its alternative.

KEYWORDS

Rheumatoid arthritis; Biologics treatment; Tumor-necrosis factor inhibitor; Infliximab.

POS0727 IMPACT OF AIR POLLUTANTS ON DISEASE ACTIVITY AMONG PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) IN MALAYSIA

Background

Systemic Lupus erythematous (SLE) is an autoimmune disease with a wide spectrum of clinical manifestations and characterized by remission and flares. Recent epidemiological studies postulated that air pollution confers an increased risk of flare in various autoimmune diseases. Haze is a common phenomenon afflicting Southeast Asia (SEA), including Malaysia, and has occurred almost every year within the last few decades.

Objectives

This study was aimed to determine the correlation and association between SLE disease activity with exposure to inhaled Particulate Matter (PM10) and Nitrogen Dioxide (NO2).

Methods

SLE patients who attended rheumatology and nephrology clinic in University Kebangsaan Malaysia Medical Centre (UKMMC) from June 2019 until March 2020 were recruited. Their medical records were reviewed for retrospective assessments of the disease activity using the Modified-SLE Disease Activity Index (M-SLEDAI) and The British Isles Lupus Assessment Group (BILAG 2004) index from January 2015 until September 2019. Clinic visits with presence of infection or recent change of immunosuppressive treatment of ≤ 3 months were excluded. The average of daily concentrations of inhaled PM10 (µg/m3), and NO2 (ppb) were evaluated within 30 days preceding the clinic visits, and the data was obtained from Department of Environment (DOE) Malaysia. Comparison of the means was performed by Student’s t-test; and the correlations between PM10, and NO2 were determined by Pearson’s correlation coefficient. The associations between the effect of daily pollutant concentrations on M-SLEDAI and BILAG 2004 scores were analyzed using the generalized estimating equation (GEE) model, while considering fixed effects for repeated measures.

Results

A total of 46 patients were recruited with 603 clinic visits were recorded. A significantly higher NO2 level was found in active disease patients with M-SLEDAI score of ≥ 4 (33.09 ± 9.15 vs 31.09 ± 9.79, p=0.32), and presence of BILAG B and/or A (score ≥ 8), 35.03± 2.97 vs 31.1 ± 9.8, p= 0.003). There were positive correlations between M-SLEDAI scores (rs 0.128, p=0.002) and BILAG scores with NO2, (rs 0.142, p<0.001). In the GEE analysis, significant correlations were found between M-SLEDAI score [OR 1.27 (95% C.I: 1.06-1.53), p=0.01] and BILAG score with NO2 [OR 1.47 (95% C.I: 1.15-2.1.88), p=0.002].

Conclusion

Our study suggests that air pollutant NO2 exposure 30 days prior to clinic visit is associated with high disease activity among patients with SLE in Malaysia. Further prospective study is warranted to confirm this finding.

References

[1]Fernandes EC, et al. Exposure to Air Pollutants and Disease Activity in Juvenile-Onset Systemic Lupus Erythematosus Patients. Arthritis Care Res (Hoboken). 2015 Nov;67(11):1609-14.

Acknowledgements

Department of Environment (DOE), Ministry of Environment And Water, Malaysia

Disclosure of Interests

None declared