A van Royen-Kerkhof

Correlation of CXCL10, Tumor Necrosis Factor Receptor Type II, and Galectin 9 With Disease Activity in Juvenile Dermatomyositis

Juvenile dermatomyositis (DM) is a systemic autoimmune disorder of unknown immunopathogenesis in which the immune system targets the microvasculature of skeletal muscles, skin, and other organs. The current mainstay of therapy is a steroid regimen in combination with other immunosuppressive treatments. To date, no validated markers for monitoring disease activity have been identified, which hampers personalized treatment. This study was undertaken to identify a panel of proteins specifically related to active disease in juvenile DM.

Autologous stem cell transplantation leads to a change in proinflammatory plasma cytokine profile of patients with juvenile dermatomyositis correlating with disease activity.

Juvenile dermatomyositis (JDM) is a rare autoimmune disorder, affecting mainly muscles and skin. The mainstay of treatment is high dose corticosteroids, combined with other immunosuppressive drugs.1 In about 30% of patients, the disease cannot be controlled despite multiple treatment interventions. Autologous stem cell transplantation (aSCT) has been reported as a last resort treatment in refractory patients with autoimmune diseases.2 The main hypothesis for the underlying immunological mechanism is that aSCT resets the immune system and restores immune tolerance following profound lymphodepletion and immune suppression.3 Here, we report three patients with refractory JDM that received aSCT (Clinical information, table 1). A short-term follow-up with detailed clinical information (including imaging before and after aSCT, and immune reconstitution after aSCT) of two patients describing complete remission was reported previously.4 The current follow-up of these patients is more than 5 years showing sustained remission. A third patient (#3) has a follow-up of nearly 3 years. Indication of aSCT for patient 3 was refractory muscle and skin inflammation comparable to the other two patients. Whole body MRI prior to aSCT confirmed active myositis. As muscle tests improved substantially after aSCT, MRI was not repeated post aSCT in this patient. Immune reconstitution …

Nonlethal transfusion associated graft-versus-host disease in a severe combined immunodeficient patient.

Summary:An X-linked severe combined immunodeficient (SCID) patient received a nonirradiated erythrocyte transfusion and developed transfusion-associated graft-versus-host disease (TAGVHD), which was controllable with high-dose corticosteroids. Haplo-identical SCT was performed, after a myeloablative conditioning regimen. At day +26, he developed GVHD. Chimerism studies revealed DNA of the erythrocyte transfusion donor (ETD) and recipient only. Because of early nonengraftment and the presence of alloreactive T cells of ETD origin, the patient was treated with an immunosuppressive conditioning regimen followed by a second SCT from the same donor. While tapering immunosuppression, he again developed mild GVHD, and DNA of ETD and bone marrow donor origin were both present. On cyclosporin, the ETD-DNA signal finally disappeared. High-resolution HLA typing revealed haplo-identity between BMD, ETD and the patient, which might have contributed to the relative mild course of the TAGVHD.

CD4+ T cell responses to epitopes of self-heat shock protein 70 in patients with juvenile dermatomyositis

Background and objectives Juvenile dermatomyositis (JDM) is a childhood disease characterised by inflammation in the muscle and the skin. In several human chronic inflammatory diseases CD4 T cell responses to epitopes of heat shock proteins (hsp) have been found to play a role, both pathogenic and regulatory. In JDM hsp70 is highly up regulated in the inflamed muscle. Therefore, hsp70 could be a target in the inflammatory process in JDM. Responses to hsp70 epitopes in JDM have not yet been characterised. In HLA elution studies it has become clear that epitopes from self-hsp70 are abundantly bound to HLA. In this study the authors tested whether peripheral blood CD4 T cell responses to hsp70-epitopes can be detected and whether they are different in JDM patients compared to healthy controls (HC). Materials and methods Hsp70-epitopes were selected based on (1) literature on HLA-elution studies, (2) HLA-class II binding capacity tested with computer models and (3) in vitro responses by CD4 T cells from healthy donors. Proliferation of PBMC from healthy controls (HC, age 2–18) and JDM patients and juvenile idiopathic arthritis patients as disease controls was tested using 3H-thymidine assays and CFSE-staining. Cytokine production was tested by Luminex analysis, flow cytometry and PCR. Results The following epitopes were selected: aa 38–52, aa 161–175, aa 290–304 and aa 443–457. These peptides were immunogenic in humans, inducing proliferation or cytokine production. The proliferation of CD4 T cells towards aa 443–457 is increased in JDM. Conclusion The authors identified novel epitopes of hsp70 that are immunogenic in healthy donors and JDM and they found indications that the CD4 T cell response towards H443 is increased in JDM.

Juvenile idiopathic arthritis in a patient with previous diagnosis of severe congenital lupus

Neonatal lupus (NL) is an acquired autoimmune disease of the newborn, caused by transplacental passage of the maternal autoantibodies anti SS-A/Ro and anti SS-B/La. When the clinical picture starts directly at birth, it is known as congenital lupus (CL). The clinical manifestations are variable. Except for cardiac involvement, the other manifestations tend to be benign, and resolve with the child’s clearance of maternal antibodies. We report a patient who presented at birth with very severe involvement of the skin, and subsequent contractures of hands and feet, leading to functional impairment. The patient underwent surgical procedures with excellent result. At the age of 18 months, the patient was diagnosed with oligoarticular juvenile idiopathic arthritis (JIA), and bilateral uveitis at the age of 3 years and a half. Our aim is to alert health professionals about the possibility of a severe course of cutaneous manifestations in CL, as well as the role of CL and NL regarding development of other autoimmune diseases.

SP0036 Share recommendations on juvenile dermatomyositis

Background In 2012, a European initiative called Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) was launched to optimise and disseminate diagnostic and management regimens in Europe for children and young adults with rheumatic diseases. Juvenile Dermatomyositis is a rare Pediatric Rheumatic Disease (PRD) , associated with significant morbidity. Evidence-based guidelines are sparse and management is mostly based on physicians9 experience. Consequently, treatment regimens differ throughout Europe. Objectives To provide recommendations for diagnosis and treatment of JDM based on evidence-informed consensus. Methods Recommendations were developed by an evidence-informed consensus process using the European League Against Rheumatism standard operating procedures. A committee was constituted, consisting of 19 experienced paediatric rheumatologists and 2 experts in paediatric exercise physiology and physical therapy, mainly from Europe. Recommendations derived from a validated systematic literature review were evaluated by an online survey and subsequently discussed at two consensus meetings using nominal group technique. Recommendations were accepted if >80% agreement was reached. Results In total, 7 overarching principles, 33 recommendations on diagnosis and 19 recommendations on therapy were accepted with >80% agreement among experts. Topics covered include assessment of skin, muscle and major organ involvement and suggested treatment pathways. Conclusions The SHARE initiative aims to identify best practices for treatment of patients suffering from PRD. Within this remit, recommendations for the diagnosis and treatment of JDM have been formulated by an evidence-informed consensus process to produce a standard of care for patients with JDM throughout Europe. SHARE – JDM Working Group B. Bader-Meunier (Department for Immunology, Hematology and Pediatric Rheumatology, Necker Hospital, Paris, France), E. Baildam (Alder Hey Children9s NHS Foundation Trust, Eaton Road, Liverpool, UK), T. Constantin (Semmelweis Hospital, Budapest, Hungary), B. Feldman (Department of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada.), P. Lahdenne (Department of Pediatric Rheumatology, Children9s Hospital, Helsinki University Central Hospital, Helsinki), B. Magnusson (Astrid Lindgren Children9s Hospital, Department for Pediatric Rheumatology, Karolinska University HospitalStockholm, Sweden), K. Nistala (Centre for Rheumatology, University College London, UK), C. Pilkington (Centre for Rheumatology, University College London, UK), A. Ravelli (Istituto Giannina Gaslini, Pediatria II, Reumatologia, Paediatric Rheumatology International Trials Organisation (PRINTO) Coordinating Center, Genoa, Italy), R. Russo (Service of Immunology and Rheumatology, Hospital de Pediatria Garrahan, Buenos Aires, Argentina), M. van Brussel (Child Development and Exercise Center, Division of Pediatrics, Wilhelmina Children9s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands), JJ. van der Net (Child Development and Exercise Center, Division of Pediatrics, Wilhelmina Children9s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands), L. Wedderburn (Centre for Rheumatology, University College London, UK), N. Wulffraat (Department of Pediatric Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands), B. Bader-Meunier (Department for Immunology, Hematology and Pediatric Rheumatology, Necker Hospital, Paris, France), E. Baildam (Alder Hey Children9s NHS Foundation Trust, Eaton Road, Liverpool, UK), T. Constantin (Semmelweis Hospital, Budapest, Hungary), B. Feldman (Department of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada), P. Lahdenne (Department of Pediatric Rheumatology, Children9s Hospital, Helsinki University Central Hospital, Helsinki), B. Magnusson (Astrid Lindgren Children9s Hospital, Department for Pediatric Rheumatology, Karolinska University HospitalStockholm, Sweden), K. Nistala (Centre for Rheumatology, University College London, UK), C. Pilkington (Centre for Rheumatology, University College London, UK), A. Ravelli (Istituto Giannina Gaslini, Pediatria II, Reumatologia, Paediatric Rheumatology International Trials Organisation (PRINTO) Coordinating Center, Genoa, Italy), R. Russo (Service of Immunology and Rheumatology, Hospital de Pediatria Garrahan, Buenos Aires, Argentina). Disclosure of Interest None declared

Targeted NGS based hereditary autoinflammatory disorder screening in routine diagnostics, two year experience in the Netherlands

Hereditary autoinflammatory diseases (AID) are characterized by recurrent bouts of systemic inflammation caused by dysregulation of the innate immunity system. The genotype-phenotype correlation can be highly variable which makes a genetic diagnosis in AID patients complex and laborious. A clear and definitive diagnosis cannot be provided for up to 80% of AID patients, which can be important for treatment options. To date, over 20 causal genes have been identified for monogenic AIDs.

AB0202 Galectin-9 is a Robust Biomarker for Disease Activity in Juvenile Dermatomyositis and Acts as a T Cell Activator

Background Juvenile dermatomyositis (JDM) is a rare, but severe chronic systemic autoimmune disease in children, characterized by muscle weakness and a typical skin rash. Clinical evaluation of disease activity remains challenging. Recently, we identified a protein that highly correlates with disease activity in a Dutch JDM cohort: galectin-9 (gal-9). The immunobiological role of gal-9 in autoimmune diseases is still controversial. On the one hand it is known for its immunosuppressive effects by inducing apoptosis in T-helper (Th) 1 and Th17 cells and activating regulatory T cells, on the other hand it has been implicated in T cell activation and Th1 skewing. Objectives To validate the potential of gal-9 as a biomarker in JDM and investigate its immunobiological effects on T cell skewing and activation. Methods Gal-9 was measured in patients serum of an independent JDM cohort by multiplex immunoassay. For functional experiments, naive CD4 T cells were isolated and stimulated with different concentrations of gal-9, plus anti-CD3 and antigen presenting cells. To test specificity, a gal-9 blocking agent (TIM-3 fusion protein) as well as a control from the galectin family (galectin-8) were included. Flow cytometric analysis of proliferation and T cell activation markers was performed on day 3 and 5 of culture. Cytokines TNFα, IFNγ, IL-13, IL-17 and IL-10 were measured in the culture supernatants of days 3, 5 and 7 by multiplex immunoassay. Results Measurement of gal-9 in serum confirmed its high discriminative value for active disease versus remission (P=.0001; AUC 0.894; OR 9.17) even under medication, as well as a strong correlation with the clinical disease activity scores CMAS and Physicians Global VAS. On a functional level, the presence of gal-9 induced a slight but significant increase in naive CD4 T cell proliferation after 3 days of culture. The T cell activation markers CD25, CD69 and TIM-3 showed the same pattern. Gal-9 also increased production of IFNγ, TNFα and IL-10, mainly at day 7. These effects were not seen in the control conditions. Conclusions We confirmed the potential use of a very robust biomarker, galectin-9, that highly correlates with disease activity in juvenile dermatomyositis. Introduction of this biomarker into clinical practice will help to personalize treatment. Functionally, we found that gal-9 is a T cell activator, causing increased proliferation, cytokine production and expression of T cell activation markers. The high levels of circulating gal-9 in JDM patients may therefore contribute to the immunopathogenesis of JDM. References Bellutti Enders et al. Correlation of CXCL10, TNFRII, and Galectin-9 With Disease Activity in Juvenile Dermatomyositis. Arthritis Rheumatol. 2014 Aug;66(8):2281-9. Disclosure of Interest None declared

PReS-FINAL-2131: Hunting for biomarkers in juvenile dermatomyositis

Juvenile Dermatomyositis (JDM) is a systemic autoimmune disorder in which the immune system targets the microvasculature of skeletal muscles, skin and other organs, with for the most part an unknown immunopathogenesis. Moreover, evaluation of disease activity remains challenging in juvenile dermatomyositis as muscle enzyme levels and inflammatory markers, routinely used in clinics, are no reliable biomarkers in JDM, especially for monitoring the disease.

Expression of CD64 (FcγRI) in skin of patients with acute GVHD

GVHD remains a major problem in allo-SCT. We explored the presence of APC in skin biopsies of GVHD patients, using the IgG receptor CD64 expression as a hallmark for activated APC. By immunohistochemistry we demonstrated CD64 to be upregulated on host APC in skin biopsies of patients with acute GVHD and, less prominently, in chronic GVHD. Double staining for CD32 polymorphism revealed CD64-positive cells to be mainly of host origin. The majority of CD64-positive cells coexpressed CD68, indicating a macrophage phenotype. Given its very restricted cellular distribution, CD64 may represent an excellent target for APC-directed therapies in GVHD.