Chien Chih Lai

Association of serum interleukin-17 and interleukin-23 levels with disease activity in Chinese patients with ankylosing spondylitis.

Background: Ankylosing spondylitis (AS) is a chronic arthritis with a pathogenesis which is not fully understood. A third subset of IL‐17‐producing T helper cells, called Th17 cells, has been discovered and characterized. We investigated whether IL‐17 and IL‐23, two Th17‐related cytokines, play any roles in the pathogenesis of, and have any correlations with, disease activity and clinical manifestations in AS. Methods: This cross‐sectional study included 49 AS patients and 25 healthy control subjects. The serum IL‐17 and IL‐23 levels were measured using enzyme‐linked immunosorbent assay kits. At the same time, C‐reactive protein (CRP), erythrocyte sedimentation rate (ESR), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Patient Global Score (BAS‐G) levels were measured, and physical examinations were performed on study participants to determine their extent of physical mobility. Results: The serum IL‐17 and IL‐23 levels of the AS patients were significantly higher than those of the healthy controls. In the AS patients, the BASDAI scores had a better correlation with the serum IL‐17 or IL‐23 levels (IL‐17, r = 0.351, p = 0.014; IL‐23, r = 0.398, p = 0.005) than with ESR (r = 0.078, p = 0.600) and CRP (r = 0.012, p = 0.993). IL‐17 or IL‐23 correlate to the BASFI, BAS‐G and parameters related to physical mobility. In the receiver operating characteristic (ROC) analysis, the serum IL‐17 and IL‐23 levels act better in discriminating patients with BASDAI≥4 (AUC value 0.88, p = 0.001) than ESR and CRP (AUC value 0.727, p = 0.008). Conclusion: Serum IL‐17 and IL‐23 levels were significantly higher in AS patients than in healthy controls and the levels correlate to disease activity measured by BASDAI scores, but not parameters of functional ability and spinal mobility. These results suggest the existence of a role of IL‐17 and IL‐23 in the pathogenesis of inflammation in AS.

Clinical features and outcomes of posterior reversible encephalopathy syndrome in patients with systemic lupus erythematosus.

To analyze the clinical features and outcomes of patients with posterior reversible encephalopathy syndrome (PRES), the risk factors of PRES‐related intracranial hemorrhage (ICH), and all‐cause mortality in patients with systemic lupus erythematosus (SLE).

Increased risk of osteoporotic fractures in patients with systemic sclerosis: a nationwide population-based study

Objectives To identify the incidence rate (IR) and risk factors of osteoporotic fractures (OFs) among systemic sclerosis (SSc) patients. Methods A cohort study was conducted using the Taiwan National Health Insurance database. Patients with SSc and respective age- and gender-matched controls without SSc were enrolled. The primary endpoint was the first occurrence of OF. The Cox proportional hazard model was used to investigate the risk factor of OFs in the SSc cohort. Results Among 1712 SSc patients (77.8% female, mean age 50.3 years) with a median follow-up of 5.2 years, 54 patients developed vertebral fractures, 17 patients developed hip fractures, and 7 patients developed radius fractures (IR: 6.99, 2.18 and 0.90 per 1000 person-years, respectively). Compared with the controls, the incidence rate ratios (IRRs) (95% CIs) among SSc patients were 1.78 (1.30 to 2.39, p<0.001) for vertebral fractures and 1.89 (1.05 to 3.22, p=0.026) for hip fractures. The IRRs for overall OFs were 1.74 (1.32 to 2.27, p<0.001) for women and 1.06 (0.33 to 2.66, p=0.856) for men. The SSc patients experienced hip fractures at a younger age (67.2 vs 75.2 years, p=0.005), and had a higher 1-year mortality rate (13% vs 3%, p=0.006) of vertebral fractures than did the controls. Multivariable Cox regression analyses indicated that older age, being female, using daily prednisolone equivalent to >7.5 mg, and bowel dysmotility treated with intravenous metoclopramide are associated with OF. Conclusions SSc patients had a high IR of vertebral and hip fractures, especially those who were female, older, used a high dose of corticosteroid or experienced bowel dysmotility.

Association of systemic lupus erythematosus with a higher risk of cervical but not trochanteric hip fracture: a nationwide population-based study.

To determine the incidence rates and risk factors of cervical and trochanteric hip fractures (HFs) among patients with systemic lupus erythematosus (SLE) based on a nationwide population‐based data set.

Increased Risk of Subarachnoid Hemorrhage in Patients With Systemic Lupus Erythematosus: A Nationwide Population‐Based Study

A relatively common occurrence of spontaneous subarachnoid hemorrhage (SAH) in patients with systemic lupus erythematosus (SLE) has been noted; however, the subsequent studies were conflicting. This nationwide population‐based study aimed to evaluate the risk of SAH in patients with SLE.

Relapsing Polychondritis Associated Refractory Airway stenosis

Relapsing polychondritis (RP) is a rare and debilitating rheumatic disease featuring recurrent and at times disseminated inflammation of cartilaginous structures, including auricles, eyes, peripheral joints, and airway1. Symptomatic airway compromise in RP is considered a common but severe cause of morbidity and mortality, which necessitates aggressive medical and bronchoscopic intervention2. We describe a refractory airway stenosis in a young patient with RP. A 24-year-old man attended our clinic because of progressive pain and swelling in his left ear that had progressed to the right side with tenderness in his right eye for 1 year. He had been diagnosed with auricle chondritis with scleritis …

Intestinal vasculitis and renal infarction in a lupus patient with antiphospholipid syndrome

A14-year-old adolescent girl with a 1-year history of systemic lupus erythematosus presented to our hospital with complaints of vomiting and diffuse abdominal dull pain for 2 days. She was taking low-dose prednisolone and hydroxychloroquine with poor drug compliance. Although she was experiencing abdominal pain, she did not have diarrhea, chills, dysuria, or flank pain. Physical examination showed malar rash, low-grade fever, but no leg edema. Palpation revealed diffuse and mild rebound tenderness without rigidity over the entire abdomen. Laboratory tests showed pancytopenia, low complement levels (C3, 26.5mg/dL [reference range, 79Y152mg/dL]; C4, 4.13mg/dL [reference range, 16Y68 mg/dL]), high titers of double-stranded DNA, antiphospholipid antibodies (aPLs) (anticardiolipin IgG, 78 Kg/mL [reference range, G12.5 Kg/mL]), and slightly elevated level of C-reactive protein, but no hypoalbuminemia or proteinuria. Computed tomographic (CT) scan of the abdomen indicated a diagnosis of mesenteric vasculitis (Fig. 1). There was

Etanercept-associated right abducens nerve palsy in rheumatoid arthritis

Dear Editor, Etanercept can significantly improve clinical outcome in both methotrexate-naı̈ve and -failure patients with rheumatoid arthritis (RA). Withdrawal of etanercept is mostly attributed to loss of efficacy or serious adverse effects, such as severe infection, congestive heart failure, malignancy, demyelinating or autoimmune disorders. Abducens nerve palsy (ANP) rarely occurs in RA during anti-tumor necrosis factor (TNF)-a treatment. Although the associations and mechanisms between ANP and anti-TNF-a agents are not fully understood, prompt recognition of this condition is important for practitioners. We report a case of RA presenting with ANP during etanercept treatment and spotlight the potential association in the management of RA. A 57-year-old woman with a 10-year history of erosive RA was admitted because of rapid-onset blurred vision, dizziness, proptosis, right eye tenderness and horizontal diplopia of 1-week duration (Fig. 1). She began using etanercept when all standard treatments for RA, including methotrexate and hydroxychloroquine, had failed and the Disease Activity Score (DAS)-28 remained high at 8.52. After receiving etanercept for 12 weeks, her DAS-28 declined from 8.52 to 3.76. However, visual impairment and abnormal eyeball movement developed at this time. Cerebral infarction and infectious disease were excluded. She had no clinical evidence of deep vein thrombosis or pulmonary thromboembolism, and her serum anti-cardiolipin antibody, functional assay of protein C and antithrombin III were all within normal ranges. She denied a previous history of trauma or surgery. Binocular intraocular pressure was normal. Other than the ANP, there were no other abnormal neurological manifestations. Magnetic resonance imaging (MRI) of the brain showed prominent right cavernous sinus with flow void signals; thus dural carotid-cavernous fistula (CCF) was considered. There was no evidence of cerebral demyelination in the brain MRI study (Fig. 2). Etanercept was terminated immediately and the patient received a course of intravenous pulse therapy

SAT0286 Risk of Severe Herpes Simplex Virus Infection in Patients Sle: A Nationwide Population Cohort Study

Background Severe herpes simplex virus (HSV) infections, especially encephalitis and keratitis, often affect immunocompromised patients and result in severe sequela. However, only few attempts have been made at the association between systemic lupus erythematosus (SLE) and HSV. Objectives To identify the risk of severe HSV infection in SLE patients by means of a nationwide population-based cohort study. Methods We identified SLE patients from the National Health Insurance research database between 1997 and 2012. We compared the incidence rate (IR) of severe HSV infection, including viral septicaemia, CNS infection, ocular infection, visceral infection and those with complications after infection, with that of non-SLE cohort. A Cox multivariable proportional hazards model was applied to evaluate the risk of severe HSV infection in the SLE cohort. Results A total of 122,520 subjects (24,504 SLE patients and 98,016 age- and gender-matched subjects as control group) were analyzed and revealed a significantly higher IR of severe HSV infection in SLE (Incidence rate ratio =3.52, p <0.001). Previous skin infection (HR=2.17, p=0.047), intravenous steroid pulse therapy (HR=4.48, p<0.001), oral daily steroid dose over 7.5mg prednisolone or equivalent (HR=1,60, p=0.010) were independent risk factors for severe HSV infection in SLE patients, while Age ≤18 (Hazard ratio [HR]=0.47, p=0.021) was a protective factor.Table 1. Risk factors of severe HSV infection in patients with SLEa Variable Univariate analysis Multivariable analysisa HR (95% CI) P-value HR (95% CI) P-value Age 1.01 (1.00–1.03) 0.017  ≤18-year-old 0.47 (0.24 – 0.89) 0.021  >18-year-old 1.23 (0.54–2.82) 0.612 Male 0.986 (0.57–1.71) 0.974 Diabetes mellitus 0.56 (0.31–1.02) 0.057 End-stage renal disease 0.96 (0.62–1.49) 0.844 Malignancy 1.12 (0.28–4.54) 0.871 CHF 0.79 (0.46–1.36) 0.399 Previous skin infection 2.21 (1.03–4.73) 0.042 2.17 (1.01–4.65) 0.047 Hydroxychloroquine 1.05 (0.75–1.46) 0.108 Azathioprine 1.60 (1.10–2.3.2) 0.015 – – Mycofenolate mofetil 0.40 (0.06–2.89) 0.367 Cyclosporine 1.58 (0.58–4.26) 0.371 Cyclophosphamide 1.67 (0.87–3.18) 0.122 MTX 1.32 (0.58–2.99) 0.507 Intravenous 5.24 (3.52–7.79) <0.001 4.48 (2.95–6.80) <0.001 Oral daily dose over 7.5mg† 2.03 (1.44–2.86) <0.001 1.60 (1.12–2.30) 0.010 Conclusions A higher risk of severe HSV infection was observed in SLE patients Risk factors for severe HSV infection were age over 18, previous skin infection, intravenous steroid pulse therapy and an oral daily steroid dose over 7.5mg. References Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus. 2013 Oct;22(12):1286–94 Bosch X, Guilabert A, Pallarés L, Cerveral R, Ramos-Casals M, Bové A, Ingelmo M, Font J. Infections in systemic lupus erythematosus: a prospective and controlled study of 110 patients. Lupus. 2006;15(9):584–9. The nature and outcome of infection in systemic lupus erythematosus. Lupus. 2002;11(4):234–9. Disclosure of Interest None declared

AB0426 Risk of Pneumocystis Carinii Pneumonia Infection in Patients with Systemic Lupus Erythematosus: A Nationwide Population Cohort Study

Background Pneumocystis carinii pneumonia (PJP) infection often affects immunocompromised patients may cause severe morbidity and mortality. PJP may be preventable by prophylactic antibiotics in high risk patients. However, the epidemiology and risk factors for PJP in patients with systemic lupus erythematosus (SLE) are not full studied. Objectives This nationwide population-based study aimed to evaluate the risk of PJP in patients with systemic lupus erythematosus in Taiwan. Methods We identified 23,378 SLE patients from the National Health Insurance research database between 1997 and 2012 and compared the incidence rate (IR) of PJP infection with that of 93,512 age- and gender-matched non-SLE cohort. A Cox multivariable proportional hazards model was applied to evaluate the risk of PJP infection in the SLE cohort. Risk factors of PJP infection were also analyzed. Results The SLE cohort had a significantly higher IR of PJP infection (SLE IR=2.49, control IR=0.10, incidence rate ratio = 26.06, p<0.001). Male (Hazard ratio [HR] = 2.05, p=0.039), end stage renal disease (HR=1.88, p=0.035), use of mycofenolate mofetil (HR=5.11, p<0.001), intravenous steroid pulse therapy (HR=96.23, p<0.001).Table 1. Risk factors of PJP infection in patients with SLE Variable Univariate analysis Multivariable analysis HR (95% CI) P-value HR (95% CI) P-value Male 2.61 (1.33–5.13) 0.005 2.05 (1.04–4.04) 0.039 Comorbidity  Diabetes mellitus 0.55 (0.20–1.53) 0.251  End-stage renal disease 3.80 (2.15–6.72) <0.001 1.88 (1.05–3.39) 0.035  ILD 2.02 (0.80–5.09) 0.137  Stroke 1.77 (0.92–3.40) 0.088  Malignancy 0.71 (0.40–1.25) 0.237 Medications  Hydroxychloroquine 0.622 (0.35–1.12) 0.108  Azathioprine 1.86 (1.01–3.42) 0.043 – -  Mycofenolate mofetil 14.58 (7.23–29.41) <0.001 5.11 (2.48–10.50) <0.001  Cyclosporine 7.55 (3.21–17.77) <0.001 – -  Cyclophosphamide 7.26 (3.80–113.89) <0.001 – -  MTX 0.619 (0.09–4.49) 0.632 Steroid  Intravenous 182.3 (65.31–508.8) <0.001 96.23 (33.46–276.82) <0.001  Oral daily dose over 7.5m† 15.87 (7.07–35.64) <0.001 3.83 (1.66–8.82) 0.002 Conclusions Higher risk of PJP infection was observed in SLE patients. Risk factors for PJP infection include male, end stage renal disease, use of mycofenolate mofetil, intravenous steroid pulse therapy and an oral daily steroid dose over 7.5mg. References Ratchaya Lertnawapan, Kitti Totemchokchyakarn, Kanokrat Nantiruj, Suchela Janwityanujit. Risk factors of Pneumocystis jeroveci pneumonia in patients with systemic lupus erythematosus. Rheumatol Int 2009;29:491–496. Michael M. Ward, Fiona Donald. Pneumocystis carinii pneumonia in patients with connective tissue diseases. Arthritis & Rheumatism 1999;42:780–789. Chia-Tse Weng, Ming-Fei Liu, Meng-Yu Weng, et al. Pneumocystis jirovecii Pneumonia in Systemic Lupus Erythematosus From Southern Taiwan. J Clin Rheumatol. 2013;19:252–8. Disclosure of Interest None declared