Ahmet Eftal Yücel

Cyclophosphamide therapy in a serious case of lupus nephritis during pregnancy

Systemic lupus erythematosus (SLE) flare is common, and renal involvement is one of the most serious problems during pregnancy. Aggressive immunosuppressive therapy should be considered for patients with diffuse proliferative lupus nephritis. These individuals are at high risk for progression to end-stage renal disease. Immunosuppressive drugs can cause significant toxic and teratogenetic effects. In this report, we describe the case of a pregnant patient with lupus nephritis who was treated with cyclophosphamide. The patient was in the second trimester of her first pregnancy and did not respond to corticosteroid therapy. She underwent intensive in-hospital care while she was on cyclophosphamide therapy. Both mother and baby were well at delivery.

Pachymeningitis and Optic Neuritis in Rheumatoid Arthritis: Successful Treatment with Cyclophosphamide

Abstract: Pachymeningitis is a rare complication of rheumatoid arthritis. The case of a 52-year-old male rheumatoid arthritis patient with pachymeningitis and optic neuritis who was successfully treated with intravenous cyclophosphamide is described.

Cholesterol crystal embolization mimicking vasculitis: success with corticosteroid and cyclophosphamide therapy in two cases

Cholesterol crystal embolization is a potential complication of atherosclerosis. Approximately one-third of the patients who develop this problem have a history of vascular surgery, angiography or angioplasty hours to weeks before onset. The skin and the kidneys are most frequently involved, but any organ can be affected. Livedo reticularis of the lower extremities and acrocyanosis (known as “blue toe syndrome”) are the most common cutaneous manifestations. Histological examination is the only way to definitively diagnose cholesterol crystal embolization. Recently, it has been proposed that cholesterol embolization is associated with vasculitis, and some authors have labeled this condition a “vasculitis look-alike.” There is still no specific treatment for this problem, even in cases that progress to renal failure. However, a few case reports in the literature have noted successful treatment with corticosteroids and cyclophosphamide in patients with deteriorating renal function. In this article, we describe two cases of severe cholesterol crystal embolization accompanied by renal dysfunction) and blue toe syndrome. Both patients benefited from corticosteroid and cyclophosphamide therapy.

Effects of infliximab treatment in terms of cardiovascular risk and insulin resistance in ankylosing spondylitis patients

Abstract Objective. To assess the effects of infliximab treatment on insulin sensitivity and cardiovascular risk factors in patients with ankylosing spondylitis (AS). Methods. In this prospective study, 30 consecutive AS patients (23 men and 7 women) fulfilling the modified 1984 New York criteria for AS were investigated. All patients were treated with intravenous infliximab. A complete biochemical profile and assesments were obtained before and after 12 weeks of infliximab therapy. The Homoeostasis Model Assessment of Insulin Resistance Index (HOMA-IR) was used to measure insulin resistance (IR). Framingham equation was used to assess cardiovascular risk factors. Results. After 12 weeks of infliximab treatment, there was no statistically significant difference in fasting insulin, HOMA-IR, lipid parameters, body–mass index, waist circumference and waist–hip ratio, whereas fasting glucose levels (p = 0.001), triglycerides/high-density lipoprotein (HDL) ratio (p = 0.043) and total cholesterol/HDL (p = 0.041) ratio increased significantly from baseline. A significant decrease was observed for both systolic blood pressures (p < 0.001) and diastolic blood pressures (p = 0.003) in the 12th-week visit. A significant decrease was also found in terms of Framingham risk scores (p = 0.028) after treatment. Conclusions. Study results suggest that infliximab treatment may reduce cardiovascular risk and blood pressures without changing IR.

Polyarteritis nodosa complicated by intrahepatic–perihepatic hemorrhage and acute appendicitis: successful treatment with cyclophosphamide and corticosteroids

Polyarteritis nodosa (PAN) is a systemic vasculitic disease characterised by necrotising inflammation of small and medium-sized arteries. Abdominal complications due to PAN are rare, but the death rate for these cases is high. We describe a serious case of PAN that involved intrahepatic–perihepatic haemorrhage and acute appendicitis. Exploratory laparotomy and appendectomy were performed, and the patient was successfully treated with cyclophosphamide and corticosteroids.

Correlation between IL-17A/F, IL-23, IL-35 and IL-12/-23 (p40) levels in peripheral blood lymphocyte cultures and disease activity in Behcet’s patients

Behcet’s disease is a chronic multisystemic disease with remissions and relapses. Several studies have shown that immune mechanisms play an important role in the development of the disease. In order to assess the association of disease activity with IL-17A/F, IL-23, IL-12/23 (p40) and IL-35 expression, we aimed to investigate production of these cytokines in peripheral blood mononuclear cells (PBMCs) from Behcet’s patients and normal controls. Furthermore, we included Systemic Lupus Erythematosus (SLE) as disease control to evaluate the specificity of our data for immunopathogenesis of BD. Totally 15 active, 15 inactive Behcet’s patients, 12 active and 12 inactive SLE patients and 12 healthy volunteers were enrolled in the study. Peripheral blood mononuclear cells were separated, lymphocyte cultures were performed and IL-17A/F, IL-12/23 p(40), IL-23, IL-35 cytokine levels were measured by ELISA in culture supernatants in the presence or absence of phytohemagglutinin (PHA) on time-dependent manner. IL-17 A/F levels increased parallel to IL-23 levels in Behcet’s and SLE patients. Compared to healthy controls, IL-17 A/F levels were higher in active Behcet’s and SLE patients; on the contrary, levels of IL-35 were lower. IL-17A/F, IL-12/23 (p40) and IL-23 levels were detectable most frequently in active Behcet’s patients followed by active SLE patients. Our results indicate that IL-17 A/F, IL-23 and IL-12/23 (p40) may play role in the immunopathogenesis of BD so as Th17 and Th1 cell responses. Since IL-35 levels were lower in active Behcet’s patients compared to inactive patients and healthy controls, there may be a plasticity between Th17 and Treg cells according to the state of disease activity.

The prevalence of spondyloarthropathy in fibromyalgia patients.

Abstract Objective: To document the prevalence of Spondyloarthropathy (SpA) with an evaluation of patients previously diagnosed with fibromyalgia syndrome (FMS). Methods: The patients diagnosed with FMS before telephoned and asked three questions to determine for inflammatory back pain. American College of Rheumatology (ACR) Fibromyalgia criteria 1990 and ACR 2010 and for diagnosing patients with SpA; criteria from the European Spondyloarthropathy Study Group (ESSG), and Amor were applied. Results: FMS was diagnosed according to 1990 ACR criteria in 14 (60.8%) SpA patients who were diagnosed with SpA according to the Amor criteria alone and in 10 (43.4%) patients who were diagnosed according to ESSG criteria alone, while it was diagnosed in 9 (33.3%) patients who were diagnosed with SpA according to Amor and ESSG criteria together and in 15 (65.2%) patients diagnosed with SpA according to Amor and/or ESSG criteria. The most tenderness was experienced in the bilateral shoulder supraspinatus tendon insertion region (57.7%) and in the sacroiliac joint (40.8%). Fourteen (60.8%) patients diagnosed according to ACR 1990 and 17 (51.6%) patients diagnosed according to ACR 2010 had plantar fasciitis and/or Achilles enthesopathy on foot radiography. Conclusions: There is a meaningful section of patients who are SpA or FMS and SpA are together in the patients thought to be FMS or the patients diagnosed with FMS according to ACR’s criteria can be said.

Nörologlar Nasıl Primer Sjögren Sendromu Tanısı Koyar

INTRODUCTION Neurological involvements were shown in 20% of patients with Primary Sjogrens Syndrome (pSS). Neurological symptoms may be the first signs of pSS in 57% of the cases. In addition, early diagnosis and treatment of neurological disorders may save or improve the quality of life of these cases. There have been reports about the neurologic manifestations of pSS but little is known about the details of neurologically presented cases. METHOD In this study, we described 11 pSS patients who presented with neurological manifestations. RESULTS Central nervous system (CNS) involvement was recorded in 7 (63.7%) and peripheric nervous system (PNS) involvement in 4 cases (36.4%). CONCLUSION Our findings regarding the cases with neurological manifestations leading to the diagnosis of pSS suggest that: 1) The frequency of CNS involvement was higher than that of PNS, and the most frequent clinical pictures of CNS involvement are Multiple Sclerosis (MS)-like illnesses and optic neuritis, 2) Guillain Barre Syndrome (GBS) was the most frequent disease of PNS involvement; 3) Mononeuropathy multiplex (MM) might be the first sign of pSS; 4) Neurologists should consider pSS in the differential diagnosis of cases with MS, optic neuritis, GBS and neuropathies of unknown causes including MM; 5) There is an urgent need of therapeutical guidelines for the cases with neurological involvement associated with pSS.

FRI0469 Endothelial Progenitor Cells in Takayasu's Arteritis

Background Takayasus arteritis (TA) is a rare, chronic inflammatory disease of unknown etiology. The inflammation in this disease leads to stenosis, thrombosis, dilatation or aneurysm in aorta and/or its branches. Endothelial progenitor cells (EPCs) are bone marrow derived immature cells which take part in revascularization and vascular homeostasis. The level of circulating EPCs increases in case of vascular injuries and tissue ischemia. Objectives There is no any specific serologic marker or biochemical test for TA. In this study we aimed to investigate the level of EPCs in patients with Takayasus arteritis. Methods A total of 26 subjects were included in this case-control study, of whom 11 and 15 subjects were TA or healthy, respectively. The diagnosis of TA is based on American College of Rheumatology TA classification criteria. Patients with a diagnosis of chronic disease other than TA, malignancy, pregnancy, infection, recent surgery or trauma were excluded. Erythrocyte sedimentation rate (ESR) and CRP levels of all subjects were measured. EPCs were defined and measured by flow cytometry according to the expression of CD146, CD31 and CD34. The MedCalc 12.7 software (Belgium) was used for all statistical analyses. The Kolmogorov-Smirnov test was used to show the normal distribution of quantitative measurements; the Chi-square was used to test the statistical significance of the differences in demographic data; and the T test or Mann Whitney U test was used for the comparison of the quantitative measurements (age, EPCs, ESR, CRP) between the two groups. The probability of making a Type I error (alpha, significance) was accepted as 0.05 in all tests. Results Groups were matched in terms of age and sex. The mean ages were 33.1±6.6 and 33.2±9.1 in the study and control groups, respectively (p=0.995). There were 9 (81.8%) and 7 (46.7%) women in the study and control groups, respectively (p=0.109). The levels of EPCs of patients with Takayasus arteritis were higher than those of controls. The mean level of EPCs was 4.18±2.67 in the study group while it was 2.13±1.30 in the control group. The difference was statistically significant (p=0.016). ESR and CRP levels were also higher in the TA group (20.3±15.5 vs. 10.7±4.9, 5.08±3.74 vs. 1.09±0.36, and p=0.033, <0.001, respectively). Conclusions Although circulating endothelial cells are found to be associated with ANCA-associated vasculitis in this study we have shown high levels of EPCs in patients with Takayasus arteritis. Takayasus arteritis is a chronic vasculitis associated with inflammation on arterial walls. Endothelial activation in affected blood vessels is a mediator of vascular inflammation. EPCs migrate to the peripheral circulation in response to pathological stimulation of vascular injury or tissue ischemia. Consequently, these cells may be a useful marker for TA. References Hristov M, Weber C. Endothelial progenitor cells: characterization, pathophysiology, and possible clinical relevance. J Cell Mol Med 2004; 8: 498-508. Arend WP, Michel BA, Bloch DA, et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990; 33: 1129-34. Haubitz M, Woywodt A. Circulating endothelial cells and vasculitis. Intern Med 2004; 43: 660-7. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1941

AB0658 The Effects of Infliximab Treatment on Depression, Anxiety and Sleep Disorders in Patients with Ankylosing Spondylitis

Background Ankylosing spondylitis (AS) is a chronic inflammatory disease which physically, psychologically, and socially affect the patients life. Objectives Previous studies have reported a correlation between severity of AS and depression, anxiety, and sleep disorders. In this study we aimed to investigate the effects of infliximab on depression, anxiety and sleep disorders in patients with AS. Methods A total of 29 AS patients whose BASDAI≥4 were enrolled. Patients were treated with intravenous infliximab (5mg/kg) at 0, 2nd and 6th week. The scores of VAS pain assessment, VAS-sleep, BASDAI, BASFI, ASQoL, mSchober, Beck depression (BDI) and Beck anxiety inventory (BAI), and the levels of chest expansion, morning stiffness, ESR, CRP were evaluated before initiation of therapy and 6 weeks after the last infusion (at 12th week). Results There were 6 (20.7%) women and 23 (79.3%) men. There were statistically significant decrement between all measurements before and after the treatment (p<0.001 for each; Table 1). There were 25 (86.2%) patients with clinically significant depression (cut-off point 17), 20 (68.96%) patients with clinically significant anxiety (cut-off point 16) before treatment. These numbers decreased to 8 (27.58%) and 4 (13.79%) respectively at 12th week. The scores of BASDAI, VAS-sleep, BDI and BAI after 6 weeks from last dose were lower than those before the treatment. There were significant correlations between BDI and BASDAI, BASFI, chest expansion, duration of morning stiffness, ASQoL (p<0.05 for each; Table 2). BAI also significantly correlated with BDI, and ASQoL (p<0.05 for each; Table 2). Table 1. The scores and measurements of patients before and after the infliximab treatment At first At 12. weeks P BASDAI 7,10±0,93 1,91±1,08 <0,001 BASFI 6,22±1,42 2,16±1,54 <0,001 ASQoL 15,48±2,44 5,10±4,89 <0,001 VAS pain 8,72±0,81 2,78±1,82 <0,001 VAS sleep 6,86±2,34 1,71±1,35 <0,001 Duration of morning stiffness (min) 93,72±26,4 16,03±10,63 <0,001 BDI 27±8,78 10,34±8,41 <0,001 BAI 20,66±11,35 8,93±8,96 <0,001 Table 2. The correlation of the differences of parameters before -after the infliximab treatment p r BDI – BASDAI 0,006 0,499 BDI – BASFI 0,009 0,474 BDI – Chest expansion 0,01 0,472 BDI – morning stiffness 0,004 0,518 BDI – ASQoL <0,001 0,783 BAI – ASQoL 0,004 0,522 Conclusions In this study, we have shown significant improvements in VAS-sleep, BDI and BAI scores after infliximab treatment. This improvement seems to be related to healing of the disease rather than the direct effect of the drug because it was correlated with the imrovement in disease activity scores. The most significant correlation was found with ASQoL supporting the accuracy of this relation. References Persoons P, Vermeire S, Demyttenaere K et al. The impact of major depressive disorder on the short and long term outcome of Crohns disease treatment with infliximab. Aliment Pharmacol Ther 2005;22:101-10 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2682