Ender Terzioglu

Development of Crohn's disease following anti-tumour necrosis factor therapy (etanercept).

Inhibition of tumour necrosis factor (TNF)‐alpha is effective in the treatment of rheumatoid arthritis and other inflammatory rheumatic diseases. Anti‐TNF antibodies such as infliximab, etanercept and adalimumab are commonly used. There are structural and functional differences among these agents. We describe development of Crohn’s disease in a patient with ankylosing spondylitis receiving anti‐TNF therapy. This case suggests that the appearance of gastrointestinal symptoms in patients on anti‐TNF therapy must be evaluated to find out whether this is a new onset or an exacerbation of underlying inflammatory bowel disease.

Platelet-activating factor and P-selectin activities in thrombotic and nonthrombotic Behçet's patients

ObjectiveThe aim of this study was to compare plasma Platelet-activating factor (PAF) and P-selectin (CD62P) activities in Behçet’s disease patients with and without thrombosis.MethodsIn this cross-sectional and descriptive study, 30 consecutive Behçet’s patients were included, 15 of them with venous thrombosis. All patients were also divided into two subgroups according to the presence or absence of clinical activity. Plasma PAF levels, basal and Ca++ ionophore (A23187)-induced leukocyte (cellular) PAF activities, and platelet-rich plasma ΔCD62P activity (the mean fluorescent density difference between CD62P phycoerythrin-positive and -negative stains) were evaluated.ResultsIn the thrombotic group, plasma PAF (P=0.001), basal leukocyte PAF (P=0.017), induced leukocyte PAF (P=0.024), and ΔCD62P (P=0.023) levels were significantly higher than in the nonthrombotic group. In the whole group of Behçet’s patients, there was a positive correlation between plasma PAF and ΔCD62P levels (r=0.533, P=0.002). When we compared clinically active and inactive patients with respect to the above parameters, there was no significant difference, irrespective of thrombosis. Plasma PAF (P=0.001), basal leukocyte PAF (P=0.004), and ΔCD62P (P=0.038) levels were significantly higher in the presence of both clinical activity and thrombosis than of clinical activity alone.ConclusionPlatelet-activating factor and CD62P may contribute to endothelial injury and thrombosis development in Behçet’s disease. These two parameters seem related to the presence of thrombosis rather than clinical activity.

CTLA-4 gene polymorphism of exon 1(+49 A/G) in Turkish systemic lupus erythematosus patients.

Cytotoxic T lymphocyte‐associated antigen‐4 is a cell‐surface molecule providing a negative signal for T cell activation. CTLA‐4 gene polymorphisms are known to be related with genetic susceptibility to various autoimmune diseases, including systemic lupus erythematosus (SLE). However, the effects of this polymorphism on clinical features of SLE have not been defined. We analysed the CTLA‐4 gene +49 A/G polymorphisms in patients with SLE by using polymerase chain reaction–restriction fragment length polymorphism (PCR–RFLP) and investigated the effect of polymorphisms on clinical outcomes. Blood was collected from 47 unrelated Turkish SLE patients, all fulfilling the American College of Rheumatology criteria for SLE, and 100 ethnically matched healthy volunteers. The AA genotype was a predominant genotype in the Turkish population and genotype frequencies of CTLA‐4 AA were significantly higher in SLE patients (70%) than healthy controls (47%) (P = 0.015). There was a statistically significant difference in the AA genotype [odds ratio (OR): 2.66, confidence interval (CI) 95%: 1.27–5.56, P = 0.014] distribution among patients and controls. There was also an increase in A allele frequency in SLE and controls, but the difference was not statistically significant (81% vs. 70%, P = 0.068, OR = 1.8, CI 95%: 0.99–3.28). Interestingly, mean age and mean age of onset disease was higher in AA homozygote SLE patients compared to non‐AA (39.2 ± 11.5 vs. 31.6 ± 10.6, P = 0.044; 32.38 vs. 24.31, P = 0.046, respectively). There was no association between genotype and the other clinical features of SLE. Our results suggested that CTLA‐4 +49 AA genotype might be a risk factor for the development of SLE in Turkish population and G allele might be involved in early development of SLE. No association with clinical features was found for polymorphism of the promoter region in CTLA‐4 +49.

Characteristics Predicting Tuberculosis Risk under Tumor Necrosis Factor-α Inhibitors: Report from a Large Multicenter Cohort with High Background Prevalence

Objective. Screening strategies for latent tuberculosis (TB) before starting tumor necrosis factor (TNF)-α inhibitors have decreased the prevalence of TB among patients who are treated with these agents. However, despite vigilant screening, TB continues to be an important problem, especially in parts of the world with a high background TB prevalence. The aim of this study was to determine the factors related to TB among a large multicenter cohort of patients who were treated with anti-TNF. Methods. Fifteen rheumatology centers participated in this study. Among the 10,434 patients who were treated with anti-TNF between September 2002 and September 2012, 73 (0.69%) had developed TB. We described the demographic features and disease characteristics of these 73 patients and compared them to 7695 patients who were treated with anti-TNF, did not develop TB, and had complete data available. Results. Among the 73 patients diagnosed with TB (39 men, 34 women, mean age 43.6 ± 13 yrs), the most frequent diagnoses were ankylosing spondylitis (n = 38) and rheumatoid arthritis (n = 25). More than half of the patients had extrapulmonary TB (39/73, 53%). Six patients died (8.2%). In the logistic regression model, types of anti-TNF drugs [infliximab (IFX), OR 3.4, 95% CI 1.88–6.10, p = 0.001] and insufficient and irregular isoniazid use (< 9 mos; OR 3.15, 95% CI 1.43–6.9, p = 0.004) were independent predictors of TB development. Conclusion. Our results suggest that TB is an important complication of anti-TNF therapies in Turkey. TB chemoprophylaxis less than 9 months and the use of IFX therapy were independent risk factors for TB development.

AB0117 New Identified IL-23 Receptor Gene Mutations in Ankylosing Spondylitis

Background The pathogenesis of ankylosing spondylitis (AS) has strongly been associated with the gene HLA-B27; however, AS occur only in 1%–5% of HLA-B27-positive individuals and increasing evidence suggests involvement of also non-HLA genes. Previous work has confirmed association with single nucleotide polymorphisms in interleukin-23 receptor (IL-23R). Objectives The aim of the study is to confirm the association of IL-23R gene polymorphisms with ankylosing spondylitis in Turkish population and to find out possible mutations responsible from this association. Methods We included 48 AS patients and 48 healthy unrelated individuals. Extracted DNA from patient specimens was amplified with polymerase chain reaction and sequenced. Results We identified 6 new point mutations at IL-23R gene in patients with AS (Table). 2824DelC mutation (1/41 - 2,4%) was found to be in the intronic region that probably does not have an effect on the protein. 34521GT mutation (1/36 - 3,8%) was located at the exon-intron boundary and changes the exon recognition site. This should be the reason for exon skipping. The mutation probably changes the protein structure and function of IL-23R protein. Ala228Ala (2/42 - 4,8% - p.0,0306) was a silent mutation that does not change the protein structure of the IL23R protein. Ala364Gly mutation (6/43–17% - p.0,074) missense mutation was found at 6 patients as a heterozygote. Ala364Gly mutation looks associated with AS. Leu371Phe mutation (1/43 - 2,3%) was also missense mutation and caused change on the aminoacid. As the last point, Tyr436Stop is a silent mutation that is an early stop truncating the protein 194 aminoacid earlier than the usual process.Table 1. Characteristics of IL-23R mutations determined in patients with ankylosing spondylitis Mutation Function Position Homozygote major genotype No. of homozygote major genotype Heterozygote genotype No. of heterozygote major genotype Homozygote minor genotype No. of homozygote minor genotype p (genotype) p (allelic) 2824DelC Intronic – –/– 40 (97.6%) –/DelC 1 (2.4%) DelC/DelC 0 0.276 0.277 34251 GT Exon skipping – GG 35 (97.2%) GT 1 (2.8%) TT 0 0.245 0.246 ALA(GCA)228ALA (GCC) Aminoacid change ALA-ALA 228 aa GG 40 (95.2%) GC 0 CC 2 (4.8%) 0.126 0.0306 ALA(GCT)364 GLY(GGT) Aminoacid change ALA-GLY 364 aa CC 37 (86%) CG 6 (14%) GG 0 0.074 0.085 LEU(TTG)371PHE (TTC) Aminoacid change LEU-PHE 371 aa GG 42 (97.7%) GC 1 (2.3%) CC 0 0.288 0.284 Tyr (TAT) 436 STOP (TAA) Tyr-Stop 436 aa Tyr/Tyr 43 (97.7%) Tyr/STOP 1 (2.3%) STOP/STOP 0 0.293 0.295 None of the mutation exist in control group. Conclusions We have determined 6 new point mutations in 11 patients included. Although two of the mutations probably do not have an effect on the protein, other four mutations cause changes in the protein structure of IL-23R protein. We consider that these mutations probably contribute to the pathogenesis of AS by effecting the functions of the protein. References Brionez TF, Reveille JD. The contribution of genes outside the major histocompatibility complex to susceptibility to ankylosing spondylitis. Curr Opin Rheumatol. 2008 Jul;20(4): 384–91. Karaderi T, Harvey D, Farrar C, et al. Association between the interleukin 23 receptor and ankylosing spondylitis is confirmed by a new UK case-control study and meta-analysis of published series. Rheumatology (Oxford). 2009 Apr;48(4):386–9. Disclosure of Interest None declared

FRI0279 Current Immunosuppressive Drugs Are Not Enough To Treat The Pulmonary Involvement of Connective Tissue Diseases

Background Interstitial lung diseases (ILDs) may occur secondary to connective tissue diseases (CTDs) and increase morbidity and mortality due to ventilation impairment. Objectives To reveal clinical, laboratory and imaging features of CTD -ILDs and to analyze treatment approaches. Methods One hundred thirty two consecutive patients were included in this cohort. Demographic characteristics, laboratory and HRCT results and treatment results were analyzed. More than 10% increase of pulmonary function tests were categorized as improvement, >10% decrease were categorized as deterioration and ±10% changes were categorized as stable disease. Results There were 111 ILD patients (86.5% CTD-ILD) with follow-up time for more than 6 months. Median follow up time was 48 (Min-Max:6–260) months and mean age was 54.5±11.9 years. HRCT scan was repeated in median 3 (1–10) times per patients, with median 12.5 month intervals. The most frequent HRCT findings were ground-glass opacities, interlobular septal thickening and honeycomb patterns. 89.6% of CTD-ILD patients recieved corticosteroids and 44.8% recieved hydroxylchloroquine sulphate. Azathioprine and cyclophosphamide were the most common used immunosupresive drugs. Eighty four patients recieved at least one immunosuppressive agent. There were only 2 patients treated with four different immunosuppressive drugs. After treatment, mean pulmonary function tests did not significanty differ from baseline (p>0.05) (Table). 35% of the patients improved forced vital capacity(FVC >%10 increase) by treatment whereas 31% had decreased and 34% were stable. Conclusions It is not detected to have significant improvement by current immunosuppressive drugs in patients with CTD-ILDs. There is need more effective novel drugs to treat for CTD-ILD. Disclosure of Interest None declared

481 Differences in Humoral and Cellular Immunity in Young and Old Individuals.

Background The immune system changes with the age. In this study we characterized immune changes by performing immunologic screening profiles on aging individuals (graduation thesis). Methods This study was performed at Akdeniz University, in the Faculty of Medicine, Dept. of Immunology. Healthy volunteers consisted of a young group (22 donors) and an older group (45 individuals). Using flow cytometry analysis, CD3, CD4, CD8, CD16, CD19, CD28, CD40, CD45, CD56, CD80, CD86, CTLA-4 and with ELISA IL-1 &bgr;, IL-2, IL-6, IL-10, IFN-&ggr;, TNF-&agr; expression were evaluated, along with and NK activity and induced cytokine expression (by bioassay/ELISA respectively). Results No statistical differences were observed between the 2 groups in expression of CD3, CD8, CD19, CD80, CD86, CD16, CD 56 or CD28. A higher frequency of expression of CD4, CTLA-4, CD40 and CD45 was seen in older subjects by comparison with young subjects. Cytokine profiles expressed by stimulated monocytes from the 2 groups showed no difference in IL-1 &bgr;, IL-2, IL-6, IL-10, TNF-&agr; and IFN-&ggr; production levels. Cytokine profiles expressed by stimulated lymphocytes from the 2 groups showed no difference in IL-1 &bgr;, IL-2, IL-6, IL-10, TNF-&agr; and IFN-&ggr; production levels. Conclusions We found increased expression levels of CD40 and CD45 levels in healthy older (>55 years old) versus young individuals (media age 28 years). CTLA-4 expression levels were also higher in elderly subjects, with no difference in CD28 expression levels between young/elderly individuals.