Antonina Minniti

Interleukin 18: A Biomarker for Differential Diagnosis Between Adult-onset Still’s Disease and Sepsis

Objective. The differential diagnosis between rheumatic diseases and infectious conditions is a great challenge in clinical practice. Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory syndrome that shares several clinical and laboratory variables with sepsis. Interleukin (IL)-18 is overexpressed in AOSD, suggesting a possible role as a disease biomarker. The aim of our study was to detect IL-18 serum levels in a cohort of patients with AOSD and sepsis and to address its possible role as a biomarker for differential diagnosis. Methods. A group of unselected patients with AOSD diagnosed according to the Yamaguchi criteria and consecutive patients with sepsis diagnosed according to the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria were enrolled. The clinical and laboratory data were collected. In the AOSD group, disease activity was assessed by Pouchot’s and Rau’s criteria. IL-18 serum levels were detected by ELISA. Results. Thirty-nine patients with AOSD and 18 patients with sepsis were enrolled. Two out of 18 patients with sepsis (11.1%) also fulfilled the Yamaguchi criteria. A significant difference was found in IL-18 serum levels between patients with active and inactive disease (p < 0.001), and it positively correlated with disease activity (p = 0.0003), ferritin serum level (p = 0.016), and erythrocyte sedimentation rate (p = 0.041). IL-18 was significantly increased in patients with AOSD when compared with sepsis (p = 0.014). For a cutoff of 148.9 pg/ml, this test had a specificity of 78.3% and a sensitivity of 88.6%. Conclusion. We have demonstrated that IL-18 can be a biomarker for differential diagnosis between AOSD and sepsis.

Clinical and biological differences between cryoglobulinaemic and hypergammaglobulinaemic purpura in primary Sjögren's syndrome: results of a large multicentre study

Objectives: To determine the clinical and laboratory differences between cryoglobulinaemic and hypergammaglobulinaemic purpura in primary Sjögren’s syndrome (pSS), in a large Italian multicentre cohort. Method: Patients were selected according to the following criteria: fulfilling the American–European classification criteria for pSS, serum cryoglobulin and gammaglobulin levels evaluated, and lack of hepatitis C virus (HCV) infection. Multinomial analyses were performed by distinguishing three groups of pSS: (i) purpura associated with cryoglobulinaemic vasculitis (CV), (ii) purpura associated with hypergammaglobulinaemic vasculitis (HGV), and (iii) pSS patients without purpura (pSS controls). Patients with purpura but without cryoglobulins or hypergammaglobulinaemia were excluded. Results: A total of 652 patients were enrolled in this study. Group 1/CV comprised 23/652 patients (3.53%), group 2/HGV 40/652 patients (6.13%), and group 3/pSS controls 589/652 (90.34%). The three groups were found to be significantly different from each other (post-estimation test: group 1/CV vs. group 3/pSS controls: p < 0.0001; group 1/CV vs. group 2/HGV: p = 0.0001; group 2/HGV vs. group 3/pSS controls: p = 0.0003), thus confirming the different phenotypes of purpura in pSS.Multivariate analyses revealed that peripheral neuropathy (p < 0.001), low C4 (p < 0.001), leucopaenia (p = 0.01), serum monoclonal component (p = 0.02), and the presence of anti-SSB/La antibodies (p = 0.02) characterized CV whereas rheumatoid factor (p = 0.001), leucopaenia (p = 0.01), serum monoclonal component (p = 0.01), and anti-SSA/Ro antibodies (p = 0.049) were significantly associated with HGV. Lymphoma was associated only with CV. Conclusions: HGV is a cutaneous vasculitis, related to a benign B-cell proliferation, whereas CV is a systemic immune complex-mediated vasculitis with complement activation and a higher risk of lymphoma, thus confirming CV but not HGV as a prelymphomatous condition in pSS.

Outcome of pregnancy in Italian patients with primary sjogren syndrome

Objective. To investigate pregnancy and fetal outcomes in patients with primary Sjögren syndrome (pSS). Methods. An obstetric history of 36 women with established diagnosis of pSS at pregnancy was obtained from a multicenter cohort of 1075 patients. In a subgroup case-control analysis, 12 deliveries in patients with pSS were compared with 96 control deliveries. Results. Thirty-six women (31 with anti-SSA/Ro and/or anti-SSB/La antibodies) with an established diagnosis of pSS had 45 pregnancies with the delivery of 40 newborns. Two miscarriages, 2 fetal deaths, and 1 induced abortion were recorded. Mean age at the first pregnancy was 33.9 years; mean number of pregnancies was 1.25; 18/40 (45%) cesarean births were delivered; mean pregnancy length was 38.5 weeks (range 32–43), with 6 preterm deliveries. The mean Apgar score at 5 min was 8.9, mean birthweight was 2920 g (range 826–4060 g). Congenital heart block (CHB) occurred in 2/40 (5%) newborns. The reported rate of breastfeeding for at least 1 month was 60.5%. In 4/40 pregnancies (10%) a flare of disease activity was observed within a year from delivery. In the case-control subgroup analysis, 12 deliveries were compared with 96 controls and no significant differences were found. Conclusion. Patients with pSS can have successful pregnancies, which might be followed by a mild relapse. CHB was the only cause of death for offspring of mothers with pSS.

Quality of Sexual Life in Women with Primary Sjögren Syndrome

Objective. To assess the quality of sexual life of women with primary Sjögren syndrome (pSS) and to identify its correlations with disease activity and damage, quality of life, and mood disorders. Methods. The quality of sexual life of 24 women with pSS was assessed with the Female Sexual Function Index (FSFI). Twenty-four healthy women, matched by age and hormonal status, were enrolled as controls. Mood disorders and quality of life were investigated using the Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study Short Form-36. Patients underwent a gynecological visit with vaginal pH measurement, cervicovaginal swabs, and Pap smears. Disease activity and damage were assessed by the European League Against Rheumatism Sjögren syndrome disease activity and damage indexes. Results. Patients with pSS showed a pathological mean FSFI score (19.1 ± 7.33) significantly different from controls (p = 0.004), both in menstruating women (p = 0.006) and in menopausal women (p = 0.03). Major differences between the 2 groups were detected in dyspareunia (p < 0.005), lubrication (p = 0.006), desire (p = 0.004), and arousal (p = 0.018). The FSFI score was inversely correlated with age (p = 0.008) and anxiety HADS (p = 0.031). No early anatomical changes, swabs, and Pap smear alterations were revealed in patients with pSS; however, vaginal pH was higher than normal in premenopausal patients (6.0 ± 0.77). Conclusion. Both premenopausal and postmenopausal women with pSS have a worse sexual quality of life. We reported a greater prevalence of dyspareunia that is statistically significant when compared with controls. The FSFI could be a useful tool to assess this topic, but has been neglected in the care of patients with pSS heretofore.

FRI0426 Sjögren Syndrome & Systemic Lupus Erythematosus: Performance of the New Slicc Criteria in the Detection of True Overlap

Background Primary Sjogren Syndrome (pSS) and Systemic Lupus Erythematosus (SLE) express a significant overlap in their clinical and immunological aspects. Moreover, SS often presents clinical and immunological manifestations included in the SLE classification criteria. A secondary SS (diagnosis according to AECG criteria) has been described in about 9-19% of SLE cases. Few data is available regarding the prevalence of a true overlap of the two disorders. Objectives To investigate the prevalence of patients with pSS who can be classified as having an overlap syndrome with SLE considering both the 1997-revised ACR criteria and the new criteria proposed in 2012 by the Systemic Lupus International Collaborating Clinics (SLICC). Methods Charts from patients with pSS (diagnosis according to AECG criteria) were retrospectively evaluated in order to collect clinical and laboratory data. Results Two-hundred seventy patients with pSS [8M, 262 F, mean age 57.8±12,5 years, mean age at diagnosis 52.6 years ±12.5, mean follow-up 5.6 years (range 0–42 years)] were considered. Taking into account the 1997-ACR criteria, 11 patients (4.1%) could be classified as having an overlap with SLE (SS-SLE). Considering the new SLICC criteria, the number of patients raise to 18 (6.7%). Both considering the old and the new criteria, the most frequent items satisfied by the SS-SLE group were: ANA, leukopenia, oral ulcer and arthritis (Table). The items responsible for the increasing number of patients fulfilling the new criteria were low complement and the presence of leukopenia, thrombocytopenia or hemolytic anemia since these are considered separately in the new criteria. Compared to the remaining patients with pSS (246 F, 8M, mean age at diagnosis 53.3±12.4 years), the SS-SLE group (18 F, mean age at pSS diagnosis 47.9±13.1 years) showed a significantly higher frequency of leukopenia (77.7% in SS-SLE vs 14.2% in pSS; p<0.001), arthritis (44.4% in SS-SLE vs 10.3% in pSS; p<0.001) and low complement (38.8% in SS-SLE vs 7.14% pSS; p<0.001). Conclusions The occurrence of a true overlap between SS and SLE is relatively infrequent and the new SLICC criteria may allow a higher sensitivity to detect such condition. The items responsible for the increased sensitivity are both the introduction of hyopocomplementemia and the separate consideration of different hematological disorders in the new classification criteria. In patients with SS-SLE, hypocomplementemia, leukopenia and arthritis appear to be the most frequent manifestations. Disclosure of Interest None declared

SAT0378 Autophagy is Up-Regulated in the Salivary Glands of Primary Sjogren's Syndrome Patients and Correlates with the Focus Score and Disease Activity

Background Autophagy is now considered as a major regulator in trafficking events that activates innate and adaptive immunity and consistent evidence supports its role in autoimmunity (1). Primary Sjogrens syndrome (pSS) is a systemic autoimmune disease characterized by infiltration of exocrine glands by T and B cells that, producing chemokines and cytokines, coordinate the chronic inflammatory process. No data on the role of autophagy in pSS are available in humans, although studies in mice demonstrated its involvement in the salivary and lacrimal gland homeostasis (2,3). Objectives We investigated the autophagy process in salivary gland tissue and in peripheral T lymphocytes from pSS patients to evaluate its possible implication in the pathogenesis of the disease. Methods 30 patients with pSS, 20 patients with sicca syndrome or non-specific-chronic-sialoadenitis and 30 healthy donors were studied. Peripheral T lymphocytes were isolated by standard procedures. Salivary gland biopsies were evaluated by i) H&E to assess histological pattern, the severity of inflammatory infiltrate and the presence of germinal centers, ii) RT-PCR for the expression of autophagy-related genes and IL-23p19 and IL-21 mRNA. Autophagy-related proteins (LC3, Atg5, p62/SQSTM1) were detected in peripheral T lymphocytes by western blot and in salivary gland by immunohistochemistry and immunofluorescence. IL-21 and IL-23p19 serum levels were measured by ELISA. Results Autophagy is up-regulated in T cells from the salivary glands, but not from the peripheral blood, of pSS patients and it is correlated with disease activity and damage indexes. Autophagy is also correlated with the local expression of the pro-inflammatory cytokines IL-21 and IL-23p19, but not with serum levels of these cytokines. Conclusions Our data show that, in pSS, T cells present high levels of autophagy, which may up-regulate the expression of pro-inflammatory cytokines, providing evidence for a role of this process in the pathogenesis of pSS and identifying a possible therapeutic target. References Pierdominici M, Vomero M, Barbati C et al. FASEB J. 2012; 26: 1400-1412. Morgan-Bathke M, Lin HH, Chibly AM et al. J Dent Res. 2013; 92: 911-917. Seo Y, Ji YW, Lee SM, et al. Cell Death Dis. 2014; 5: e1309. Disclosure of Interest None declared

THU0681 Baseline ESSDAI/DAS scores in 8061 patients with primary sjÖgren syndrome: characterization of systemic disease

Objectives To characterize and quantify systemic involvement at diagnosis in a large international cohort of patients with primary Sjögrens syndrome (SS). Methods The Big Data Sjögren Project was formed in 2014 to take a “high-definition” picture of primary SS at diagnosis by merging international databases (9302 consecutive patients from 21 countries of the 5 continents). The main features (including ESSDAI/DAS) at diagnosis were analysed. Results Baseline ESSDAI was available in 8061 patients (93% female, mean age 53yrs). The mean ESSDAI score at diagnosis of the entire cohort was 6.4±7.9. In 1498 patients (19%), score at diagnosis was 0, while 681 (8%) presented with high activity in at least one domain. The main systemic features at diagnosis were biological (51%), articular (38%), haematological (24%) and glandular (22%). Low DAS was reported in 4480 (56%) patients, moderate DAS in 2483 (31%) and high DAS in 1098 (14%) patients. The mean baseline ESSDAI was higher the younger the patient was (p<0.001), higher in White patients (6.9 vs 5.1, p<0.001), males (8.4 vs 6.2, p<0.001), those with positive ocular (6.7 vs 4.9, p<0.001) or oral (6.8 vs 6.2, p=0.016) tests, and those with ANA (6.9 vs 4.5, p<0.001), RF (7.5 vs 5.8, p<0.001) and anti-Ro/La antibodies (7.2 vs 4.4, p<0.001). Logistic regression identified as independent variables White ethnicity (OR 3.07), abnormal ocular tests (OR 2.14), ANA (OR 1.67) and Ro/La autoantibodies (OR 2.78). Conclusions This is the largest series of patients with primary SS in whom the ESSDAI score has been evaluated. Primary SS is undeniably a systemic disease even at the time of diagnosis, with nearly 80% of patients showing an ESSDAI score >0. Disclosure of Interest None declared

SAT0305 Histology of minor salivary glands in patients with sjÖgren's syndrome, association with clinical and laboratory aspects

Background Minor salivary gland (MSG) biopsy represents an useful tool not only for the diagnosis of primary Sjogrens Syndrome (pSS) but also to evaluate patients prognosis. Recognition of germinal centers (GCs) by hematoxilin eosin (HE) and/or IHC staining for follicular dendritic cells (FDC) detection is mandatory, representing a risk factor for lymphoma development. Focus score (FS) is one of the main instrument to quantify MSG impairment, nonetheless quality information regarding the type of infiltrate such as the entity, structure and localization, are lacking. Objectives Aim of this study is to find any association of specific histological features of MSG from patients with pSS with the principal clinical and laboratory features. Moreover, to investigate the utility of histological parameters, other than FS or GCs, for characterizing patients. Methods Patients with pSS were enrolled in our SS clinic, and clinical/laboratory data (table) referring to the time of MSG biopsy, gathered on a dedicated database. MSG, removed for diagnostic purposes, were preserved as paraffin embedded tissue, then cut and sequentially stained by H&E and IHC [polyclonal rabbit anti-CD3 (lymphocytes T); monoclonal mouse anti-CD20 (lymphocytes B); monoclonal mouse anti-CD21 (FDC)]. Images were collected by Zeiss Axio Scan and analysed (ZEN software) as follows: FS calculation, mean foci area, percentage of infiltration, presence of segregated foci (SF) (specifically, clear evidence of T and B cells area by CD3-CD20 double staining), GCs and lymphoepithelial lesions (LELs) detection. Results 53 MSG from patients with pSS were collected and analysed. Patients clinical and laboratory data are reported in table. FS positively correlated with the percentage of infiltration (p<0.001) as well as with the presence of SF (p=0.005), GCs (p=0.02) and LELs (P=0.005). Mean foci area and percentage of infiltration correlated with SF (p=0.0002 and p<0.001, respectively), GCs (p=0.0004 and p<0.001, respectively) and LELs (both p<0.001). SF correlated with GCs and LEL (p<0.001). Anti nuclear antibodies (ANA) were associated with the presence of SF (p=0.029, OR=5.7 CI=1.1–28.8) while gland swelling was associated with the presence of GCs (p=0.043, OR=4, CI=1.1–15). Conclusions The FS was associated with the presence of GCs and LELs, as well as with more organized infiltrates characterized by segregation in T and B areas (SF), thus representing an useful tool which mirrors the risk of lymphoma. From our study, the qualitative characteristics of the biopsy, including SF, percentage of infiltration or the mean foci area, appear to be strictly linked. Moreover, their association with the presence of GCs and LELs supports the importance to consider also these features during histological examination. The lack of correlation between histological parameters and clinical/laboratory features might reveal a weaker connection between histological findings and specific SS phenotypes except for the relationship between glandular swelling and GCs which confirms how this clinical aspect should be considered as a risk factor for lymphoma development. Disclosure of Interest None declared

Extraglandular Involvement in Sjögren’s Syndrome

Sjogren’s syndrome (SS) mainly affects the exocrine glands, resulting in a wide range of disturbing sicca symptoms, such as dry mouth, dry eyes, xerotrachea, and dry vagina. However, extraglandular disease manifestations can also occur in a non-negligible percentage of patients. Indeed, up to 75 % of patients with SS present extraglandular systemic features, which may be severe in about 10–20 %. Extraglandular disease includes neurological, joint, renal, and hematological manifestations.

FRI0282 Serological biomarkers of b-cell lymphoproliferative disorders in patients with primary sjögren’s syndrome: retrospective study in a large italian cohort

Background primary Sjögren’s syndrome (pSS) is the autoimmune disease with the highest risk of lymphoma. Lymphoma and mixed cryoglobulinemic vasculitis (CV) occur in a minority of cases, but they are the most relevant clinical features characterizing the B cell lymphoproliferation in pSS. Objectives to provide serological biomarkers associated with lymphoproliferative complications (B-cell lymphoma, cryoglobulinemic vasculitis (CV) and non malignant major salivary gland swelling) in primary Sjögren’s syndrome (pSS). Methods data in 1170 patients with pSS diagnosis were retrospectively collected. The analyses were then performed in patients fulfilling the following criteria: 1. European or AECG criteria, 2. Hepatitis C virus infection antibody negative, 3. serum cryoglobulins tested. Multinomial analyses (P<0.05) were performed by distinguishing 4 groups: 1. lymphoma (including patients with lymphoma and CV associated), 2. CV without lymphoma, 3. Salivary gland swelling without lymphoma, 4. other pSS patients. Group 4 was assumed as “base outcome”. The following variables were considered: presence/absence of antinuclear antibodies, anti-Ro, anti-La, low C3, low C4, rheumatoid factor, hypergammaglobulinemia, monoclonal component, leucopoenia, and cryoglobulinemia. Results 661 patients were selected. Group 1 comprised 40/661 (6.1%), group 2 comprised 17/661 (2.6%), group 3 comprised 180/661 (27.2%), and group 4 comprised 424 (64.1%). Anti-La, hypergammaglobulinemia (IgG > 16 g/l), leucopoenia (<3000/mmc), rheumatoid factor, serum monoclonal component, low C3, low C4, and cryoglobulinemia were selected by univariate analyses. Low C4 [relative-risk ratio (RRR) 8.3, 95% CI 3.6-19.2], anti-La (RRR 5.2, 95% CI 2.3-11.9), cryoglobulins (RRR 6.8, 95% CI 2.1-22.1) and leucopenia (RRR 3.3, 95% CI 1.5-7.05) were the selected variables, by multinomial logistic analyses, that distinguished group 1 from group 4. At least one of the biomarkers selected by univariate analyses was present in all patients with lymphoma, and at least one of the biomarkers selected by multivariate analyses were present in 39/40 patients with lymphoma (97.5%). The majority of variables distinguishing Group 1 from Group 4 were shared with Group 2, while rheumatoid factor and hypergammaglobulinemia were shared with Group 3. Conclusions Serological biomarkers which raise the level of suspicion of lymphoma or suggest a close follow-up in pSS patients may be identified and confirmed. Rheumatoid factor and hypergammaglobulinemia may reflect the B-cell hyperactivation in patients with salivary gland swelling, which predisposes to lymphoma in pSS. The absence of all the lymphoma-associated biomarkers in pSS may identify patients at lower risk of lymphoma, when CV or salivary gland swelling are not present. Disclosure of Interest: None Declared