F. Franceschini

Pregnancy outcome in 100 women with autoimmune diseases and anti-Ro=SSA antibodies: a prospective controlled study

Anti-Ro/SSA antibodies are associated with neonatal lupus but are also considered a possible cause for unexplainedpregnancy loss and adverse pregnancy outcome. In a large multicentres cohort study we have prospectivelyfollowed 100 anti-Ro/SSA positivewomen (53 systemic lupus erythematosus (SLE)) during their 122 pregnancies and 107 anti-Ro/SSA negative women (58 SLE) (140 pregnancies).Anti-Ro/SSA antibodies were tested by immunoblot and counterimmunoelectrophoresis. Mean gestational age at delivery (38 vs 37.9 weeks), prevalence of pregnancy loss (9.9 vs 18.6%), preterm birth (21.3 vs 13.9%), cesarean sections (49.2 vs 53.4%), premature rupture of membranes(4.9 vs 8.1%), preeclampsia(6.6 vs 8.1%), intrauterinegrowth retardation(0 vs 2.3%) and newborns small for gestationalage (11.5 vs 5.8%) were similar in anti-Ro/SSA positive and negative SLE mothers; findings were similar in non-SLE women. Two cases of congenital heart block were observed out of 100 anti-Ro/SSA positive women. In conclusion, anti-Ro/SSA antibodies are responsiblefor congenitalheart block but do not affect other pregnancyoutcomes,both in SLE and in non-SLE women. The general outcome of these pregnancies is now very good, if prospectively followedby multidisciplinaryteams with ample experiencein this field.

Treatment with etanercept in six patients with chronic hepatitis C infection and systemic autoimmune diseases

OBJECTIVEnTo describe the clinical and immunologic features of 6 patients with rheumatic disease and Hepatitis C Virus (HCV) chronic infection, treated with anti-TNF alpha drugs.nnnPATIENTS AND METHODSnSix patients, with repeated positive serology for HCV infection, were affected by Rheumatoid arthritis (RA) (4 cases), Psoriatic Arthritis (PsA) and Polymyositis in one case each. They started anti-TNFalpha treatment (Etanercept), due to a previous failure of combination of different immunosuppressants (Methotrexate, Sulfasalazine, Cyclosporine, Hydroxychloroquine).nnnRESULTSnPatients (3 female and 3 males) showed a mean age at disease onset of 50.6 years (SD 14.5) and a mean disease duration of 12.5 years (SD: 8.8). Etanercept (dosage of 50 mg weekly) was continued for a median period of 14 months. Patients affected by RA and PsA achieved a good clinical response, with a significant reduction of DAS28 during treatment (p: 0.0001). No patient received any specific therapy for HCV infection. Elevated HCV-RNA titres were recorded in 5 cases at start of Etanercept. No significant increase was observed during anti-TNF alpha treatment. No cases of hepatic failure were recorded.nnnCONCLUSIONnAnti-TNF alpha therapy showed to be effective, safe and well tolerated in the setting of HCV infection.

Prevalence and clinical associations of anti-Ku antibodies in systemic autoimmune diseases

We retrospectively analysed the prevalence and clinical features associated to anti-Ku antibodies in patients affected by different autoimmune diseases. Anti-Ku antibodies are detected in 147 sera out of 7239 anti-ENA positive sera (2%). They are found in 2% of patients with systemic sclerosis (SSc) (8 out of 379), 1.8% of systemic lupus erythematosus (SLE) (7 out of 372) and 1.8% of undifferentiated connective tissue disease (UCTD) (9 out of 496) and more rarely in Sjögren Syndrome and rheumatoid arthritis. Most of anti-Ku positive patients were affected by UCTD and overlap syndromes, including polymyositis, SSc and SLE. Interstitial lung disease, myositis, articular symptoms, Raynaud’s phenomenon and sicca represents the main clinical features detected in our cohort. The rate and severity of pulmonary disease is similar to those found in other SSc patients. Isolated anti-Ku were detected in about 47% of sera. No clinical differences were observed between these patients and subjects with multiple anti-nuclear specificities. However, anti-Ku are usually detected in association with other serological markers in SLE and Sjögren Syndrome, while they occurred isolated in SSc and polymyositis.

Anti-HMGCR antibodies as a biomarker for immune-mediated necrotizing myopathies: A history of statins and experience from a large international multi-center study

In an effort to find naturally occurring substances that reduce cholesterol by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), statins were first discovered by Endo in 1972. With the widespread prescription and use of statins to decrease morbidity from myocardial infarction and stroke, it was noted that approximately 5% of all statin users experienced muscle pain and weakness during treatment. In a smaller proportion of patients, the myopathy progressed to severe morbidity marked by proximal weakness and severe muscle wasting. Remarkably, Mammen and colleagues were the first to discover that the molecular target of statins, 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR), is an autoantibody target in patients that develop an immune-mediated necrotizing myopathy (IMNM). These observations have been confirmed in a number of studies but, until today, a multi-center, international study of IMNM, related idiopathic inflammatory myopathies (IIM), other auto-inflammatory conditions and controls has not been published. Accordingly, an international, multi-center study investigated the utility of anti-HMGCR antibodies in the diagnosis of statin-associated IMNM in comparison to different forms of IIM and controls. This study included samples from patients with different forms of IIM (n=1250) and patients with other diseases (n=656) that were collected from twelve sites and tested for anti-HMGCR antibodies by ELISA. This study confirmed that anti-HMGCR autoantibodies, when found in conjunction with statin use, characterize a subset of IIM who are older and have necrosis on muscle biopsy. Taken together, the data to date indicates that testing for anti-HMGCR antibodies is important in the differential diagnosis of IIM and might be considered for future classification criteria.

Hepatitis C virus infection and primary Sjögren's syndrome: a clinical and serologic description of 9 patients.

OBJECTIVEnTo define the clinical and immunologic profile of 9 patients with Sjögrens Syndrome (SS) and Hepatitis C virus (HCV) infection.nnnPATIENTSn9 out of 305 patients with SS, diagnosed according to the criteria proposed in 2002, had repeated positive serology for HCV.nnnRESULTSn9 female patients were studied. The mean age at onset of SS was 59 years, with a mean period of follow-up of 7.1 years. All the patients had glandular manifestations and they were all positive for dacryologic tests. Salivary gland biopsy was performed in 4 patients, all showing characteristic lymphocytic infiltrate. The main extraglandular features were arthralgias, photosensitivity, purpura, thyroiditis. All the patients were positive for anti-nuclear antibodies (ANA): 6 anti-Ro/SSA, 3 anti-Ro/SSA and anti-La/SSB positive. HCV-positive SS were compared with 296 patients with primary SS. They showed higher mean age (p=0.01), higher prevalence of photosensitivity (p=0.0266) and circulating cryoglobulins (p=0.0372). In primary SS, most patients had anti-Ro/SSA antibodies alone (49.8%) or associated to anti-La/SSB (46.5%). Five patients (1.8%) had other ANA specificities.nnnCONCLUSIONSnA chronic HCV infection is concomitant in about 3% of patients with pSS. They differ from patients without HCV infection for the higher prevalence of photosensitivity and cryoglobulins, without clinical manifestations of cryoglobulinemia.

Rare autoantibodies to cellular antigens in systemic lupus erythematosus.

Objective A high number of antinuclear antibody specificities can be detected in systemic lupus erythematosus (SLE). Some of them are related to a distinct clinical subset of disease, independently of their frequency. The aim of our study was to investigate, in a cohort of SLE patients, the prevalence and the clinical relevance of autoantibodies to cellular antigens less frequently found in SLE. Methods Antinuclear antibodies were detected by indirect immunofluorescence on HEp-2 cells while counterimmunoelectrophoresis was used to detect anti-ENA antibodies in 540 patients with SLE, classified according to ACR and SLICC criteria. Clinical and serological features were collected from clinical charts. Results A total of 319 (58.9%) out of 540 sera were positive for anti-ENA antibodies. Anti-Ro/SSA was found in 235 sera, 50 of which also contained anti-La/SSB. Anti-U1RNP were detected in 67, anti-Sm in 46 and anti-ribosomal P protein in 13 sera. In a multivariate analysis anti-Sm was associated with discoid lupus (pu2009=u20090.045) and photosensitivity (pu2009=u20090.037), anti-U1RNP with malar rash and Raynaud’s phenomenon (pu2009=u20090.01 and pu2009=u20090.0004, respectively) and anti-Ro/SSA with malar rash, oral ulcers, xerostomia, xerophthalmia and rheumatoid factor (pu2009=u20090.029, pu2009=u20090.01, pu2009=u20090.031, pu2009=u20090.002 and pu2009=u20090.028, respectively). Other anti-ENA antibodies were found in 50 positive sera (15.6%). Anti-Ki antibodies were detected in 31, anti-Ku in 8, anti-centromere in 5, isolated anti-La/SSB, anti-PCNA and anti-Topo I in 3 each and anti-Jo-1 in 2 sera. About half of these antibodies (27 out of 50) were detected as the single anti-ENA specificity in serum. At multivariate analysis anti-Ki was significantly associated with male gender while anti-Ku with African ethnicity (pu2009=u20090.017 and pu2009<u20090.0001, respectively). No sign of muscular or pulmonary involvement was found in anti-Jo-1-positive patients whilst features of systemic sclerosis were detectable in two out of three anti-Topo I. Conclusions Our study shows that antibodies to cellular antigens more rarely found in SLE are detectable in more than 15% of patients with anti-ENA antibodies. Most of them are found as single anti-ENA specificity. Anti-Ki and anti-Ku are found in a subset of disease, characterized by male gender and African origin, respectively. Clinical features of scleroderma were found only in patients with anti-Topo I.

Clinical and serological features of 35 patients with anti-Ki autoantibodies.

The objective of this study was to analyse clinical and serological associations of anti-Ki antibodies. Thirty-five patients with anti-Ki antibodies, detected by CIE, selected from laboratory routine, were studied. All patients were affected by autoimmune diseases: SLE and pSS were the most frequent diagnoses. The cohort was constituted by 27 female and eight males. Main clinical features were skin involvement (60%), xerophtalmia (48.6%), Raynaud’s phenomenon (43%), photosensitivity (34%), xerostomia (31.4%). CNS involvement was present in four (11.4%) and renal disease in seven cases (20%). ANA, anti-dsDNA and RF were detected in 100%, 60% and 34.5%. In SLE, anti-Ki was detected in 6% of cases, more frequently in males compared to other SLE patients without anti-Ki (P < 0.004). Nineteen anti-Ki positive patients affected by SLE showed more frequently malar rash and multiple autoantibody specificities compared to 16 anti-Ki positive patients with other diseases (P = 0.044 and P = 0.0003, respectively). Our study confirms a preferential occurrence of anti-Ki antibodies in patients with sicca and skin involvement. Malar rash and multiple ANA specificities were significantly associated with SLE compared to other diseases in our study. Anti-Ki were detected in 6% of patients with SLE with a significant prevalence in males.

The role of clinically significant antiphospholipid antibodies in systemic lupus erythematosus

The objective is to investigate the role of clinically significant antiphospholipid antibodies (aPL) in a cohort of systemic lupus erythematosus (SLE) patients. All SLE patients followed for at least 5 years and with available aPL profile at the beginning of the follow-up in our center were studied. Clinically significant aPL were defined as: positive lupus anticoagulant test, anti-cardiolipin and/or anti- β2Glycoprotein I IgG/IgM >99th percentile on two or more occasions at least 12 weeks apart. Patients with and without clinically significant aPL were compared by univariate (Chi square or Fishers exact test for categorical variables and Students t or Mann-Whitney test for continuous variables) and multivariate analysis (logistic regression analysis). P values <0.05 were considered significant. Among 317 SLE patients studied, 117 (37%) had a clinically significant aPL profile at baseline. Such patients showed at univariate analysis an increased prevalence of deep venous thrombosis, pulmonary embolism, cardiac valvular disease, cognitive dysfunction and antiphospholipid syndrome (APS), but a reduced prevalence of acute cutaneous lupus and anti-extractable nuclear antigens (ENA) when compared with patients without clinically significant aPL. Multivariate analysis confirmed the association between clinically significant aPL and reduced risk of acute cutaneous lupus [p=0.003, odds ratio (OR) 0.43] and ENA positivity (p<0.001, OR 0.37), with increased risk of cardiac valvular disease (p=0.024, OR 3.1) and APS (p<0.0001, OR 51.12). Triple positivity was the most frequent profile and was significantly associated to APS (p<0.0001, OR 28.43). Our study showed that one third of SLE patients had clinically significant aPL, and that this is associated with an increased risk, especially for triple positive, of APS, and to a different clinical and serological pattern of disease even in the absence of APS.

Anti-topoisomerase-I antibodies in systemic lupus erythematosus and potential association with the presence of anti-dsDNA antibodies

Sir, Anti-topoisomerase I antibody (Scl-70) targets a DNA-linked protein and is considered a specific marker for systemic sclerosis (SSc). Some case reports and a cohort study reported the occurrence of Scl-70 in up to 25% of patients with systemic lupus erythematosus (SLE), with a great variability related to the different methods employed, antigen source or cut-off levels. Scl-70 detected in SLE sera seem to recognize different epitopes (located in a region between aminoacids 300 and 400) compared with epitopes specific for Scl-70 in SSc. In addition, antibody titres are usually far higher in SSc than in SLE. The purpose of this work is to analyse the prevalence of Scl-70 in SLE with a highly sensitive method (such as CLIA) and to correlate Scl-70 positive sera with peculiar clinical and serological features. We collected 170 sera: 130 SLE and 40 controls (20 Raynaud’s without the criteria for SSc, 10 SSc and 10 healthy subjects). The SLE group was composed of 95% Caucasian patients, 93% female, with a low disease activity at the moment of evaluation (mean SLEDAI-2K: 2.68, standard deviation (SD): 2.6). They showed arthritis in 27%, malar rash in 50%, subacute cutaneous lupus in 10%, glomerulonephritis in 36%, serositis in 13% and cytopenia in 45% of cases. All sera were tested for anti-ENA, including Scl70, with counter-immunoelectrophoresis (CIE); for Scl-70, anti-dsDNA and anti-chromatine antibodies with CLIA BioFlash (IL diagnostics, San Diego, CA). Antibodies to dsDNA were also tested by a radioimmunoassay (RIA, Farr assay; Kodak). BioFlash CLIA showed an overall sensitivity and specificity of 83%–100% and 94%–99%, respectively, for anti-ENA detection, while sensitivity and specificity of 36% and 98,7%, respectively, was reported for anti-Scl70, using Baculovirusrecombinant Scl-70 antigen. Cohen k test was performed to compare the agreement of CLIA and CIE. Anti-Scl-70 was detected in 10/170 sera (5.9%) by CLIA and in 6/170 sera (3.5%) by CIE. In particular, six sera were CLIA Scl-70þ/CIE Scl-70þ, while four sera were CLIA Scl-70þ/CIE Scl-70-; Cohen k analysis reported a good agreement (k1⁄4 0.73). The 6 CLIA Scl-70þ/CIE Scl-70þ were all SSc patients, therefore analysing only SSc patients, the agreement was perfect (k1⁄4 1). No CLIA Scl-70þ/CIE Scl-70þ was found in SLE (k1⁄4 0, no agreement). AntiScl-70 were found by CLIA in 3/130 SLE (2.3%). Only four sera were discordant (Scl70þ by CLIA, negative by CIE): clinical and demographic features of these patients (three SLE and one Raynaud’s phenomenon) are reported in Table 1. Interestingly, only one out of the three patients developed a clinical picture resembling SSc, even though not classifiable as SSc. In SLE, Scl-70 are detected in 2.3% of sera by a very sensitive CLIA, but none was positive by CIE. We previously reported that CIE was far less sensitive than CLIA, detecting only three Scl-70 in a cohort of 540 SLE (0.55%). Nonetheless we found a perfect agreement between the two assays for SSc and a very good agreement when other controls were tested. The three Scl-70 positive SLE sera were all antidsDNA and anti-chromatin positive thus confirming the relationship between anti-DNA and DNA binding protein such as topoisomerase-I. We therefore conclude that further studies are needed to evaluate their clinical significance, and can predict overlap between SSc and SLE.

Macrophage activation syndrome in adult systemic lupus erythematosus: report of seven adult cases from a single Italian rheumatology center

The aim was to describe the macrophage activation syndrome (MAS), a life-threatening syndrome characterized by excessive immune activation that can be triggered by conditions affecting immune homeostasis, in a cohort of adult Italian patients with systemic lupus erythematosus (SLE). This was a monocentric retrospective evaluation. The utility of the H-score, developed to estimate the individual risk of having reactive MAS in adult patients, was assessed. Among 511 patients with SLE, 7 cases (1.4%) of MAS (all females) were identified and their medical records reviewed. In all cases, MAS was simultaneous to the onset of SLE. All patients had fever, lymphadenopathy, hematological involvement, and high titer of anti-dsDNA antibodies. Workup for infections and malignancies was negative. In all cases, the H-score was higher than the cut-off suggested for the classification of reactive MAS. All cases required hospital admission, and 2 patients were admitted to the intensive care unit. Most patients were treated successfully with high doses of corticosteroids and with immunosuppressive drugs, whereas the full therapeutic regimen developed for primary hemophagocytic lymphohistiocytosis HLH was used only in one case. No death from MAS was observed. MAS is a rare and severe disorder that complicated the onset of SLE in our cohort. The H-score may be useful in the classification of these patients.