E. Pigatto

High reactive oxygen species in fibrotic and nonfibrotic skin of patients with diffuse cutaneous systemic sclerosis

Systemic sclerosis (SSc) is a chronic multisystemic connective tissue disease characterized by progressive fibrosis affecting skin and internal organs. Despite serious efforts to unveil the pathogenic mechanisms of SSc, they are still unclear. High levels of reactive oxygen species (ROS) in affected patients have been shown, and ROS are suggested to play a role in fibrosis pathogenesis. In this study we evaluate ROS levels in nonfibrotic and fibrotic skin of patients with SSc and we compare them with those obtained from healthy controls. We enrolled nine SSc patients fulfilling the EULAR/ACR classification criteria and seven healthy controls. Patients included four men and five women with mean age of 46 ± 10 years. Controls were matched by sex and age. All patients were affected by the diffuse cutaneous form of SSc and the ANA pattern anti-Scl70. Mean disease duration was 7.5 ± 5 years. Skin involvement was evaluated by modified Rodnan skin score. Skin samples (4-mm punch biopsy) were taken from fibrotic skin and nonfibrotic skin of patients and from healthy controls as well. To detect ROS, specimens were analyzed immediately after sampling by electron paramagnetic resonance spectroscopy. Blood samples were drawn from all patients and controls to assess oxidative stress biomarkers. ROS levels (expressed as median and range, in nmol/L/min/mg of dry weight) were 24.7 (10.9-47.0) in fibrotic skin, 18.7 (7.3-34.0) in nonfibrotic skin, and 7.7 (3.5-13.6) in healthy control skin. ROS levels in fibrotic and nonfibrotic skin of SSc patients were significantly higher than in healthy controls (p = 0.002 and p = 0.009, respectively). ROS levels in fibrotic skin were raised in comparison to nonfibrotic skin, when samples related to each patient were compared (p = 0.01). ROS levels in fibrotic skin were correlated with forced vital capacity (r = -0.75, p = 0.02) and erythrocyte sedimentation rate (r = 0.70, p = 0.04). All other clinical and lab parameters showed no significant correlation. Compared to controls, blood from SSc patients showed lower ascorbate (vitamin C) levels (8 (3.8-9.8) vs 10.5 (9-19.1) mg/L, p = 0.004) and higher lipid peroxides (873.5 (342-1973) vs 422 (105-576) μmol/L, p = 0.004). Our results indicate the presence of high oxidative stress in both nonfibrotic skin and fibrotic skin of SSc patients, but with higher tendency in the latter. Raised ROS levels in nonfibrotic skin of SSc patients might be a hint of early involvement in skin fibrogenesis. However, a longitudinal prospective study is necessary for such proof.

Evaluation of right ventricular function performed by 3D-echocardiography in scleroderma patients.

The impairment of the right ventricle (RV) in systemic sclerosis (SSc) is usually related to pulmonary arterial hypertension (PAH). New echocardiographic techniques, such as 3-dimensional echocardiography (3DE) and 2-dimensional speckle tracking (2DSTE), allow an accurate evaluation of the RV function. The aim of this study was to evaluate the RV function using 3DE and 2DSTE in SSc patients with no history of heart disease and no PAH. Forty-five SSc patients, 42 females and 3 males, 28 with limited cutaneous SSc (lcSSc) and 17 with diffuse cutaneous SSc (dcSSc), were studied. Forty-three age- and gender-matched healthy subjects were enrolled as controls. All of them underwent a 3DE and 2DSTE ecocardiographic evaluation of the RV function. Systolic pulmonary arterial pressure (sPAP) and total pulmonary vascular resistance (tPVR) were also estimated by power doppler. RV echocardiographic parameters were compared in the different subsets of SSc patients. A statistical analysis was performed by t-test, ANOVA and multiple logistic regression. RV areas in 2DSTE and volumes in 3DE were higher and RV function parameters were reduced in SSc patients compared with controls. Also sPAP and tVPR were higher, but they did not reach pathological values. Echocardiographic alterations were more pronounced in patients with lcSSc. 3DE and 2DSTE echocardiography allowed us to detect morphological and functional alterations of the RV in a group of SSc patients with no clinical signs of heart disease and no PAH. These patients had significantly higher sPAP and tPVR than healthy controls without reporting values compatible with PAH. These data suggest that RV alterations are related to a pressure overload rather than to an intrinsic myocardial involvement in SSc.

A case of neuromyotonia in Behçet disease during TNF-α antagonist therapy

Neuromyotonia is a rare disorder, characterized by the presence of diffuse peripheral nerve hyperexcitability, which manifests itself with spontaneous muscle twitching, cramps and impaired muscular relaxation [1]. Behçet disease is a multisystem inflammatory vasculitis, which mainly targets the skin, mucosae and the eye. Central nervous system involvement occurs in about 10 % of patients and is a serious cause of long-term morbidity and mortality. On the contrary, peripheral nerve involvement in this condition remains an exceedingly rare and as yet debated entity [2]. We report a case of neuromyotonia in a patient with Behçet disease, which became evident during treatment with Tumor Necrosis Factor a (TNF-a) antagonists. A 36-year-old man presented with spondylarthritis and chronic diarrhea. After few months, he developed recurrent oral and genital aphthous lesions, which allowed clinicians to diagnose the clinical picture as Behçet disease. One year after symptoms onset, he was started on Infliximab owing to unsatisfying control of mucosal and gastrointestinal manifestations of the disorder by standard immunosuppressant therapy. After 5 months of treatment inconstant twitches of right biceps brachialis and both femoral quadriceps muscles emerged, accompanied by hands and feet paresthesias. Owing to the suspect of an anti-TNF-a toxicity, Infliximab was withdrawn. The involuntary muscular activity abated almost completely. Brain and spine magnetic resonance (MRI) and electroneurogram (ENG) were performed and did not uncover any abnormality. The patient was shifted back to his old medications (steroids, colchicine, aminosalicylates). Six months after, his neurologic conditions being stable, a further attempt with a TNFa antagonist was decided. Golimumab was introduced, producing an immediate and sustained relief of patient’s general conditions. Unfortunately after 6 months of this therapy, the involuntary twitches reappeared, spreading to all limbs, abdominal and thoracic musculature and later involving orbicularis oculi district. The aberrant activity became persistent. It was enhanced by movements and persisted during sleep. The patient started complaining of muscular rigidity and experienced episodes of altered proprioception of his limbs. Golimumab was stopped, but symptoms did not improve significantly. Since the raising severity of the manifestations, the patient was admitted to our Unit. Neurologic examination revealed mild hyposthenia of intrinsic hand muscles and brisk, symmetric deep tendon reflexes. Neither sensory nor cerebellar abnormalities, nor cranial nerve disturbances were detected. Inspection demonstrated the presence of fluctuating twitches of right femoral quadriceps. Action provoked the diffusion of the involuntary activity to other body regions, sometimes with a tremor-like appearance. Brain and spinal MRI were performed and again did not show any abnormality. Blood tests and cerebrospinal fluid analysis were negative, as well as auto-antibodies screening, including anti Voltage-Gated Potassium Channel (VGKC). Motor and sensory nerve conduction studies were unremarkable, M. Belluzzo (&) F. Monti Neurology Unit, Department of Medical, Surgical and Health Sciences, Azienda Ospedaliero-universitaria Ospedali Riuniti, University of Trieste, Strada di Fiume, 447, 34100 Trieste, Italy e-mail: marco.belluzzo@hotmail.com

Hypovitaminosis D in an hospitalized old population of Western Friuli.

OBJECTIVES Hypovitaminosis D is very common in the elderly in Italy and generally in the world, contributing to bone fractures and muscle weakness. The aim of the study was to evaluate bone metabolism in an old population of patients hospitalized not for musculo-skeletal complaints. METHODS The clinical records of 175 patients, 98 female and 77 male, aged >65 years, hospitalized in a Department of Internal Medicine (Sacile, Western Friuli) were retrospectively reviewed. Serum levels of calcium, phosphorous, alkaline phosphatase, parathyroid hormone (PTH) and 25-OH vitamin D were evaluated. Correlations between these parameters were investigate. RESULTS Abnormalities of bone metabolism parameters were frequently founded, particularly hypocalcemia, increased PTH and reduced 25-OH vitamin D. Hypovitaminosis D were detected in 88% of patients, low levels in 30.28% and very low levels in 57.72%. Hypovitaminosis D was related to female sex, old age of patients and high levels of PTH. CONCLUSIONS Our data confirm that hypovitaminosis D is very common in elderly population. The study has been performed in an Italian Region where the supplementation of vitamin D in the elderly is not performed, suggesting that a awareness campaign of the doctors could be very useful to prevent bone metabolism abnormalities.

Long-term improvement in activities of daily living in women with systemic sclerosis attending occupational therapy

Introduction Systemic sclerosis often affects hand function, leading to severe disability in many subjects. There is little data available on the effects of occupational therapy in systemic sclerosis in current literature. The aim of our study was therefore to evaluate the effects of a cycle of occupational therapy on performing activities of daily living in a group of women with systemic sclerosis. Method Twenty women with systemic sclerosis were included in the study: 10 followed a cycle of occupational therapy; 10 were enrolled as controls. An occupational therapy cycle consisted of six meetings of 90 minutes each over a 3-week period. All women were evaluated by the Health Assessment Questionnaire and Evaluation of Daily Activity Questionnaire at baseline and after 24 weeks. The use of devices and alternative strategies was also assessed. Results We observed a significant reduction in the Health Assessment Questionnaire and Evaluation of Daily Activity Questionnaire scores in occupational therapy subjects after 6 months compared to controls. There was also evidence of significant improvement in four dimensions of the Evaluation of Daily Activity Questionnaire: eating; indoor mobility; outdoor mobility; and communication. The number of devices in the occupational therapy group increased significantly. Conclusion Our findings suggest a relevant role for occupational therapy in improving activities of daily living in women with systemic sclerosis. The use of strategies learned during occupational therapy sessions allows for long-lasting beneficial effects.

SAT0194 IL-6 Serum Levels and Coronary Microvascular Dysfunction in Patients with Systemic Sclerosis

Background Functional impairment of coronary microcirculation is thought to be a pathway in the development of cardiac involvement in systemic sclerosis (SSc). The underlying mechanism is not fully understood. A reduction of coronary flow reserve (CFR) suggests a coronary microvascular dysfunction (CMD) and predicts adverse outcomes in several cardiovascular diseases. Interleukin-6 (IL-6) is involved in the pathogenesis of SSc and it is a marker of immune activation. High serum levels of IL-6 are correlated with the severity of skin lesions, pulmonary fibrosis and pulmonary hypertension, but the role of IL-6 in the development of cardiomyopathy in SSc is yet not clear. Objectives To assess the relationship between CFR values and IL-6 serum levels in SSc. Methods Forty SSc patients (32 female and 8 male, aged 55±11 years), classified according to the 2013 ACR/EULAR criteria, were enrolled. Disease activity was evaluated by EUSTAR score. Twenty-three patients were affected by diffuse cutaneous form and 17 by limited form. All patients had no clinical evidence of heart disease. Coronary flow velocity in the left anterior descending coronary artery was detected by transthoracic Doppler echocardiography at rest and during adenosine infusion. CFR was the ratio of hyperaemic diastolic flow velocity (DFV) to resting DFV. A CFR ≤2.5 was considered abnormal and marker of CMD. Serum levels of IL-6 and of cardiac biomarkers (pro-BNP and troponin I) were evaluated in all patients. Results CFR was reduced in 21 patients (52.5%). The average value was 2.08±0.29. Serum levels of IL-6 (n.v. <2.5 pg/mL), pro-BNP (n.v. <125 ng/L) and troponin I (n.v. <0.0017 μg/L) were increased respectively in 50%, 45% and 27.5% of cases. No significant correlation between CFR and subsets of SSc was found. Higher EUSTAR score were correlated with reduced CFR (p=0.037) and high values of IL-6 (p=0.002). A significant correlation between the increase levels of IL-6 and the reduction of CFR (p=0.039) was found. Conclusions Our results showed that high serum levels of IL-6 are associated with CMD independently from the severity of SSc. A positive correlation between IL-6, EUSTAR score and the impairment of CFR in SSc patients may be suggest an implication of IL-6 in the cardiac pathogenesis of SSc. The evaluation of serum IL-6 might represent a tool for the prediction of CMD, suggesting a role in the increased cardiovascular risk in patients with SSc. Moreover they could open new possibilities for the treatment of SSc cardiomyopathy. Disclosure of Interest None declared

AB0692 Association of Anti-SCL70 Antibodies with Coronary Microvascular Dysfunction in Patients with Systemic Sclerosis

Background Functional impairment of coronary microcirculation is thought to be a major pathway in the development of primary cardiac involvement in systemic sclerosis (SSc); however, the underlying mechanism is not fully understood. Moreover, coronary microvascular dysfunction (CMD) predicts major adverse outcomes in several cardiovascular diseases. Specific autoantibodies represent a serologic hallmark which have relevance in the diagnosis and prognosis of SSc. Some biomarkers are involved in the pathogenesis of SSc: endothelin-1 (ET-1, marker of endothelial dysfunction), interleukin-6 and iterleukin-17 (IL-6 and IL-17, markers of immune activation), and transforming growth factor-β (TGF-β, marker of fibroblast stimulation). Objectives To assess the relationship between coronary flow reserve (CFR), a marker of CMD, and specific autoantibodies: antitopoisomerase I (anti-Scl70) and anticentromere (ACA). Methods Fifty-four patients (30 F, 24 M, aged 58±12 years) with cutaneous diffuse (n=24) or limited (n=30) SSc, without clinical evidence of heart disease, and 50 healthy controls were enrolled. Activity score (1) was calculated in all patients. Coronary flow velocity in the left anterior descending coronary artery was detected by transthoracic Doppler echocardiography (TDE) at rest and during adenosine infusion. CFR was the ratio of hyperaemic diastolic flow velocity (DFV) to resting DFV. A CFR≤2.5 was considered abnormal and marker of CMD. Antitopoisomerase I (anti-Scl70) antibodies, anticentromere (ACA) antibodies, IL-6, IL17, ET-1 and TGF-β were investigated in all patients. Results CFR was lower in patients with SSc than in healthy controls (2.3±0.7 vs 3.5±0.4, p<0.0001). The prevalence of CMD was higher in patients than in controls (61% vs 3%, p<0.0001). CFR was related to time from diagnosis (r=-0.318, p=0.01), activity score (r=-0.432, p=0.006), IL-6 (r=-0.321, p=0.04) and ET-1 (r=-0.320, p=0.04). Patients with CMD (CFR≤2.5) showed an higher activity score (2.4±1 vs 1.2±0.8, p=0.008). Scl70 antibodies were more frequent in the diffuse form of SSc (p<0.0001). CFR was lower in patients with anti-Scl70 antibodies compared to patients with ACA antibodies (2.1±0.6 vs 2.6±0.8, p=0.02) (Figure), but comparable in patients with diffuse and limited form of SSc (2.36±0.6 vs 2.34±0.8, p=0.9). Moreover, CMD was more frequent in patients with anti-Scl70 antibodies compared to patients with ACA antibodies (73% vs 49%, p=0.04), whereas CMD was equally present in diffuse and limited form of SSc (62.5% vs 60%, p=0.8). Conclusions Our data show that anti-Scl70 antibodies are associated with coronary microvascular dysfunction independently from the cutaneous form of SSc. The evaluation of specific autoantibodies could represent a tool for the prediction of coronary microvascular dysfunction, a severe organ involvement in this disease. References Valentini G et al. Ann Rheum Dis 2001 Disclosure of Interest None declared

FRI0585 Nailfold Videocapillaroscopy: An Open Window on Coronary Microvascular Dysfunction in Systemic Sclerosis

Background Cardiac involvement is an important determinant of prognosis in systemic sclerosis (SSc). The identification of patients with high risk has a great importance and coronary microvascular dysfunction (CMD) predicts major adverse outcomes in several cardiovascular diseases (1). Nailfold video capillaroscopy (NVC) represents an essential tool in the classification criteria for SSc and the best method to analyse microvascular abnormalities in these patients. Objectives To assess the relationship between nailfold capillaroscopy-derived scores and coronary flow reserve (CFR), a marker of CMD, in SSc. Methods Twenty-three patients (20 F, 3 M, aged 59±12 years), 13 with diffuse and 12 with limited form of SSc, without clinical evidence of heart disease, and 23 healthy controls were enrolled. All patients underwent NVC. According to Sulli et al. the capillaroscopic parameters considered were: presence of enlarged and giant capillaries, haemorrhages, loss of capillaries (avascular score), microvascular disarray, and capillary ramifications. For each field was adopted a semiquantitative rating scale to score each capillary abnormality (1). Coronary flow velocity in the left anterior descending coronary artery was detected by transthoracic Doppler echocardiography (TDE) at rest and during adenosine infusion. CFR was the ratio of hyperaemic diastolic flow velocity (DFV) to resting DFV. A CFR≤2.5 was considered abnormal and marker of CMD. Results CFR was lower in patients with SSc than in healthy controls (2.2±0.8 vs 3.6±0.6, p<0.0001). The prevalence of CMD was higher in patients than in controls (65% vs 4%, p<0.0001). CFR was inversely related to avascular score (Figure A) and capillary ramification (r=-0.473, p=0.02). In patients with CMD (CFR≤2.5) avascular score was higher (0.78±0.06 vs 0.22±0.1, p=0.02) (Figure B). No relationship with other NVC scores was found. An exploratory receiver-operator characteristic analysis identified avascular score>0.27 (AUC 0.80, p=0.01) as the best discriminating threshold for CMD (Sensitivity 73%, Specificity 75%, NPV 60%, PPV 84%; OR 2.93, p=0.02). Conclusions Our study showes that microvascular abnormalities at NVC correlate with CMD in SSc. The evaluation of NVC in SSc might represent a tool for the prediction of coronary microvascular dysfunction, by considering the systemic microvascular derangement at the capillary nailfold. References Pepine CJ et al. JACC 2010. Sulli A et all. Ann Rheum Dis 2008. Disclosure of Interest None declared

AB0616 RO/SSA Autoantibodies in A Cohort of 552 Scleroderma Patients

Background Autoantibodies to Ro/SSA antigens have been demonstrated in 15-38% of patients with Systemic sclerosis (SSc) but their association with clinical manifestation and other serological patterns is not clear (1,2,3). Objectives The aim of our study was to verify the prevalence of anti-SSA pattern in our cohort of patients with SSc. We also analyzed the clinical features of these patients, particularly the organ involvement. Methods The retrospective review involved patients with SSc admitted to the Rheumatology Unit (University of Padova) from 1983 to 2013. By our data-base we obtained the demographic characteristics of patients, the antinuclear antibodies (ANA) specificity and the prevalence of the main visceral involvement. ANA were assayed by counter-immunoelectrophoresis (CIE). Lung involvement (ILD) was diagnosed if DLCO was <70% of predicted and forced vital capacity was <75% of predicted, or interstitial disease was note on chest radiogram or on HRTC. Heart involvment was defined in the presence of conduction defects or arhytmias on ECG and/or left ventricular diastolic dysfunction on echocardiogram. Pulmonary arterial hypertension (PAH) was estimated by Doppler echocardiogram (>45 mm Hg). Scleroderma renal crisis was defined by rapidly progressive renal failure and malignant arterial hypertension. Results Our cohort consisted of 552 SSc patients, 71 males (13%) and 481 (87%) females, with mean age at diagnosis of 46.9±14.1 yrs; 155 patients (28%) were affected by diffuse and 397 (72%) by limited cutaneous form of SSc. ANA were positive in all patients. Anti-SSA pattern was found in 23 cases (4.2%); it was associated to anti-topoisomerase I in 15 (65.2%) and to anti-centromere in 8 (34.8%). Patients with anti-SSA pattern were 19 women and 4 men, with mean age at diagnosis of 49.6±12.9 yrs; 14 had the diffuse (60.9%) and 9 the limited cutaneous form (39.1%) of SSc. ILD was diagnosed in 14 cases (60.9%), cardiomyopathy in 4 (17.4%), PAH in 2 (8.7%). No patient developed scleroderma renal crisis. The frequency of organ involvement was similar to that of the entire cohort of SSc patients, except for scleroderma renal crisis. Conclusions The prevalence of anti-SSA pattern in our cohort of SSc patients was lower than that reported by other Authors, probably because the assay method (CIE) was more specific but less sensitive than others. Anti-SSA autoantibody does not seem to affect the clinical features, in particular the visceral involvement. This conclusion is in agreement with Parker et al. (1) and Fujimoto et al. (2), while Hudson et al. report a higher frequency of ILD in patients with anti-SSA pattern (3). References Parker JC, Burlingame RW, Bunn CC. J Autoimmune Dis. 2009; 6;6:2. Fujimoto M, Shimozuma M, Yazawa N et al. Ann Rheum Dis. 1997; 56:667-70. Hudson M, Pope J, Mahler M et al. Arthritis Res Ther. 2012, 14:R50. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5134