Alexandros Sarantopoulos

Hepatitis B virus reactivation in hepatitis B virus surface antigen negative patients receiving immunosuppression: A hidden threat

AIM To present the characteristics and the course of a series of anti-hepatitis B virus core antibody (HBc) antibody positive patients, who experienced hepatitis B virus (HBV) reactivation after immunosuppression. METHODS We retrospectively evaluated in our tertiary centers the medical records of hepatitis B virus surface antigen (HBsAg) negative patients who suffered from HBV reactivation after chemotherapy or immunosuppression during a 3-year period (2009-2011). Accordingly, the clinical, laboratory and virological characteristics of 10 anti-HBc (+) anti-HBs (-)/HBsAg (-) and 4 anti-HBc (+)/antiHBs (+)/HBsAg (-) patients, who developed HBV reactivation after the initiation of chemotherapy or immunosuppressive treatment were analyzed. Quantitative determination of HBV DNA during reactivation was performed in all cases by a quantitative real time polymerase chain reaction kit (COBAS Taqman HBV Test; cut-off of detection: 6 IU/mL). RESULTS Twelve out of 14 patients were males; median age 74.5 years. In 71.4% of them the primary diagnosis was hematologic malignancy; 78.6% had received rituximab (R) as part of the immunosuppressive regimen. The median time from last chemotherapy schedule till HBV reactivation for 10 out of 11 patients who received R was 3 (range 2-17) mo. Three patients (21.4%) deteriorated, manifesting ascites and hepatic encephalopathy and 2 (14.3%) of them died due to liver failure. CONCLUSION HBsAg-negative anti-HBc antibody positive patients can develop HBV reactivation even 2 years after stopping immunosuppression, whereas prompt antiviral treatment on diagnosis of reactivation can be lifesaving.

Chronic Brucellosis Patients Retain Low Frequency of CD4+ T-Lymphocytes Expressing CD25 and CD28 after Escherichia coli LPS Stimulation of PHA-Cultured PBMCs

Chronic brucellosis patients display a defective Th1 response to PHA. We have previously shown that heat-killed B. abortus (HKBA) can downregulate the PHA-induced increase of CD4+/CD25+ and CD14+/CD80+ cells of brucellosis patients. In the present study, we investigate the effect of E. coli LPS, as a potent stimulant of monocytes and autologous T-lymphocytes, on the PHA-cultured PBMCs of the same groups of patients. Thirteen acute brucellosis (AB) patients, 22 chronic brucellosis (CB) patients, 11 “cured” subjects, and 15 healthy volunteers were studied. The percentage of CD4+/CD25+ and CD4+/CD28+ T-lymphocytes as well as CD14+/CD80+ monocytes were analyzed by flow cytometry after PBMCs culture with PHA plus E. coli LPS. A significant decrease in the percentage of CD4+/CD25+ and CD4+/CD28+ T-lymphocytes was observed in CB compared to AB. In HKBA cultures, compared to E. coli LPS-cultures, there was a significant reduction of CD4+/CD25+ T-lymphocytes in all groups and CD14+/CD80+ in patients groups. We suggest that Brucella can modulate host immune response, leading to T-cell anergy and chronic infection.

The influence of therapy on CD4+CD25highFOXP3+ regulatory T cells in systemic lupus erythematosus patients: a prospective study

Objectives: Regulatory T cells (Tregs) are inversely correlated to disease activity in systemic lupus erythematosus (SLE). However, little is known concerning the influence of immunosuppressive agents on Tregs, which was the objective of this study. Method: Thirty-five patients with SLE (29 females, six males, mean age 42.4 ± 12.8 years) were included. CD4CD25highFOXP3 Tregs were prospectively assessed by flow cytometry every month for intravenous (iv) and quarterly for oral regimens. Clinical assessment was made with the SLE Disease Activity Index (SLEDAI). Statistical analysis was performed with a Student’s t-test; p < 0.05 was considered significant. Results: In total, 44 cases of SLE relapse were treated with iv cyclophosphamide (CYP, n = 10), iv methylprednisolone (MP, n = 7), iv immunoglobulins (IVIGs, n = 5), oral MP (n = 8), oral MP  azathioprine (AZA, n = 8), and hydroxychloroquine (HCQ, n = 6). CYP, iv MP, and IVIGs resulted in a significant increase in Tregs (4.2 ± 1.6 vs. 10.1 ± 5.7, 2.9 ± 1.3 vs. 10.6 ± 4.8, and 5.6 ± 2.7 vs. 15.2 ± 6.3 cells/mm3, respectively, p < 0.05). Oral MP, alone or combined with AZA, led to a significant increase in Tregs (7.4 ± 2.5 vs. 11.8 ± 3.8 and 5.1 ± 2.4 vs. 9.4 ± 3.6 cells/mm3, respectively, p < 0.05), as did HCQ (8.2 ± 2.4 vs. 12.8 ± 2.7 cells/mm3, p < 0.05). Time to Tregs recovery was significantly shorter with iv MP and IVIGs compared to CYP (1.4 ± 0.5, 1.6 ± 0.9, and 4.0 ± 1.5 months, respectively, p < 0.05). Conclusions: Increase in Tregs during SLE remission is independent of the therapeutic regimen used and probably represents an epiphenomenon of disease remission. Time to Tregs restoration was significantly shorter in patients treated with iv MP and IVIGs compared to CYP pulse therapy.

Tocilizumab Treatment Leads to a Rapid and Sustained Increase in Treg Cell Levels in Rheumatoid Arthritis Patients: Comment on the Article by Thiolat et al

To the Editor: In their recent article in Arthritis & Rheumatology, Thiolat and colleagues reported a significant expansion in the number of Treg cells in 15 rheumatoid arthritis (RA) patients after 3 months of treatment with tocilizumab (TCZ) (1). We have observed that the increase in Treg cell frequency occurs even sooner after the initiation of TCZ treatment (shortly after the first infusion) and is sustained over at least 12 months of regular drug administration. We studied 22 patients with active RA who were administered TCZ monthly (5 patients received 12 infusions, 4 received 8, 3 received 6, 3 received 4, and 7 received 2) along with disease-modifying antirheumatic drugs (DMARDs) at stable doses. Corticosteroids were not used throughout the study. Levels of CD25FoxP3 CD4 Treg cells were assessed before every TCZ infusion. After the first infusion, Treg cell frequencies were significantly increased and the 28-joint Disease Activity Score (2) was decreased (Table 1); this increment was sustained over the subsequent months. Related studies have assessed Treg cell levels after 2 months (3) or 3 months (1,4) of TCZ administration. Our results show that a significant increase in Treg cell frequency occurs after only 1 infusion; furthermore, the increase remains stable over time. Whether TCZ or another drug(s) is the direct cause of the Treg cell expansion or whether this is the result of disease remission remains a matter of controversy. In this context, corticosteroids (used in moderate doses in previous studies) (4) are known to increase Treg cell levels in other systemic autoimmune diseases, e.g., systemic lupus erythematosus (5). In our patients (who did not receive corticosteroids during the study), DMARDs were administered at stable doses; therefore, it is quite unlikely that the Treg cell expansion could be attributed to these drugs. In conclusion, TCZ is expected to skew the Th17/Treg cell balance toward the protective Treg cell arm (6,7) The exact mechanism(s) behind this action, the duration of the increase in Treg cell frequency, and its clinical significance remain to be determined.

Increase of peripheral T regulatory cells during remission induction with cyclophosphamide in active systemic lupus erythematosus.

Cyclophosphamide efficacy in lupus nephritis (LN) and neuropsychiatric systemic lupus erythematosus (NPSLE) is probably mediated by a non‐specific ablation of reactive lymphocytes. However, little is known in regard to its effect on T regulatory cells (Tregs) in such patients, which was the aim of this study.

Influenza A/H1N1 septic shock in a patient with systemic lupus erythematosus. A case report

BackgroundImmunocompromised patients, such as systemic lupus erythematosus (SLE) sufferers have an increased risk of mortality, following influenza infection. In the recent pandemic, influenza A H1NI virus caused 18449 deaths, mainly because of adult respiratory distress syndrome or bacterial co-infections.Case PresentationIn this case report, an SLE patient with viral-induced septic shock, without overt pulmonary involvement, is discussed. The patient was administered oseltamivir and supportive treatment, including wide-spectrum antibiotics, vasopressors and steroids, according to the guidelines proposed for bacterial sepsis and septic shock. She finally survived and experienced a lupus flare soon after intensive care unit (ICU) discharge.ConclusionsTo our knowledge, this is the first case to report severe septic shock from influenza A/H1N1 virus, without overt pulmonary involvement.

Concurrent relapsing central nervous system and ocular involvement in a case of life-threatening Adamantiades-Behçet Disease (ABD).

Adamantiades-Behçet disease (ABD) is characterised by oral and genital ulcerations, skin lesions and ocular manifestations and, rarely, by central nervous system (CNS) involvement. Neuro-Behçet disease (NBD) is categorised to parenchymal or non-parenchymal, while combined CNS disease is rarely reported in the literature. A case of NBD, with severe relapsing ocular and neurological disease of combined pattern is presented. Neurological complications included brainstem manifestations, as well as neurovascular involvement, while ocular involvement consisted of bilateral uveitis and branch retinal vein occlusion. Manifestations responded to corticosteroid plus cyclophosphamide pulse therapy. Maintenance therapy included cyclosporine A, azathioprine and corticosteroids. Case individualities are discussed, focusing on scepticism concerning treatment of NBD relapses in the long term.

Systemic Sclerosis and Silicone Breast Implant: A Case Report and Review of the Literature

Environmentally induced systemic sclerosis is a well-recognized condition, which is correlated with exposure to various chemical compounds or drugs. However, development of scleroderma-like disease after exposure to silicone has always been a controversial issue and, over time, it has triggered spirited debate whether there is a certain association or not. Herein, we report the case of a 35-year-old female who developed Raynauds phenomenon and, finally, systemic sclerosis shortly after silicone breast implantation surgery.

FRI0280 Cd4+cd25highfoxp3+ t regulatory cells as a biomarker of disease activity in systemic lupus erythematosus: a prospective study

Background Low numbers of T regulatory cells (Tregs) in active systemic lupus erythematosus (SLE) are believed to reflect the breakdown of immune tolerance in disease pathogenesis. However, it is not clear if these cells may be utilized as a biomarker in assessing disease activity. Objectives of the present study was the prospective evaluation of Tregs as possible biomarkers in assessing SLE activity. Methods Tregs (phenotype CD4+CD25highFOXP3+) were assessed by flow cytometry in 285 separate blood samples from 100 white Caucasian SLE patients and 20 healthy controls. Patients were divided, according to disease activity (as measured by Systemic Lupus Erythematosus Disease Activity Index, SLEDAI) into groups A (n=39, samples=94, SLEDAI=0), B (n=33, samples=92, SLEDAI=1-5), C (n=10, samples=53, SLEDAI=6-10) and D (n=18, samples=46, SLEDAI>10). Longitudinal measurements were performed in 131 cases (37 relapses, 44 remissions and 50 cases without alteration in disease activity). Statistics were performed by Student’s t-test or one-way ANOVA, post hoc analysis with Bonferroni multiple comparisons test and correlations with Pearson co-efficient; while p<0.05 was considered significant. Results Tregs were found significantly lower in severely active disease (group D), compared to healthy controls, inactive disease, mild and moderate disease activity (0.57±0.16% vs. 1.49±0.19%, 1.19±0.34% and 1.05±0.36%, 0.72±0.21%, p<0.05, respectively). There was a strongly inverse correlation between Tregs and SLEDAI (r=-0.644, p<0.001). Alterations in disease activity were characterized by inverse alterations in Tregs: relapse (from 1.23±0.44% to 0.64±0.19%, p<0.001, mean change 0.59±0.41%), remission (from 0.65±0.27% to 1.17±0.30%, p<0.001, mean change 0.52±0.35%). In cases with unaltered disease activity, Tregs numbers remained stable (from 0.98±0.35% to 1.03±0.34%, p=0.245). Tregs were practically halved during relapse (mean reduction 42.6±22.2%), and doubled during remission (mean increment 113±120.9%). Mean change of Tregs in cases with unaltered activity was significantly lower (7.3±20.6%, p<0.001). A clinically significant change in SLEDAI (sum of cases with relapse and remission, n=81) was followed by a significant (>20%) inverse change in Tregs in 71/81 cases (sensitivity 87.7%). In the 50 cases of unchanged SLEDAI, Tregs were significantly changed (>20%) in 13 cases (specificity 74%). Positive predictive value (PPV) was 84.5% and negative predictive value (NPV) was 78.7%. Conclusions CD4+CD25highFOXP3+ T regulatory cells displayed a strongly inverse correlation to disease activity, while their alterations reflected the changes in SLEDAI with high sensitivity. These cells may be a promising biomarker for the assessment of disease activity in SLE by longitudinal measurements. Disclosure of Interest: None Declared

Celiac trunk aneurysm in a patient with Adamantiades-Behçet disease

Major artery involvement in Adamantiades-Behcet disease (ABD) ranges from 5% to 18% and mainly manifests as arterial stenosis and/or aneurysm formation.1 Celiac artery involvement is considered rare; celiac aneurysms have been reported in isolated cases.2,3 We present computed tomography (CT) angiography of a 70-year-old male, suffering from ABD for 40 years (initial symptoms included recurrent oral and genital ulcerations and bilateral anterior uveitis). Treatment, over time, included methylprednisolone, cyclosporine and azathioprine. He was admitted for severe upper abdominal pain, accompanied by nausea and abdominal distension. Laboratory investigation showed elevated erythrocyte sedimentation rate and C-reactive protein. Abdominal CT angiography revealed a celiac artery aneurysm starting 2 mm from the aorta measuring 32 mm in length and with a maximum diameter of 16.7 mm (Panel A) with thrombus attached in the arterial wall. Additionally, the common hepatic artery was totally occluded; hepatic perfusion was sustained via the superior mesenteric and pancreatoduodenal arteries (Panel B). Intravenous methylprednisolone pulses (1000 mg/day for 5 consecutive days) were administered with satisfactory response. Maintenance treatment included methylprednisolone and mycophenolate mofetil, along with antiplatelet therapy (aspirin plus clopidogrel). After 12 months, repeated abdominal CT angiography revealed stabilization of the celiac artery aneurysm (maximum diameter 16.3 mm). During this period, the patient remained asymptomatic. Celiac artery aneurysm in ABD represents a rare entity and may require combined medical and surgical intervention. Urgent surgery, either by open or endovascular repair, is mandatory in case of enlarging or ruptured aneurysms or due to organ-threatening ischemia.3,4 Equally significant is the implementation of postoperative immunosuppressive therapy, to prevent relapse and common complications after arterial bypass surgery, such as graft occlusion and new aneurysm formation at the site of anastomoses. Remission induction with immunosuppressive drugs represents the first goal in uncomplicated cases of ABD, while Images in Vascular Medicine