G. Kearns

Photoprotective behaviour and sunscreen use: impact on vitamin D levels in cutaneous lupus erythematosus

Background: Sun exposure of the skin, independent of dietary sources, may provide sufficient vitamin D in healthy individuals. A recent study of patients with cutaneous lupus erythematosus concluded that over 70% of them restrict their sun exposure.

Enhanced interferon regulatory factor 3 binding to the interleukin‐23p19 promoter correlates with enhanced interleukin‐23 expression in systemic lupus erythematosus

OBJECTIVE To examine the role of interferon regulatory factor 3 (IRF-3) in the regulation of interleukin-23 (IL-23) production in patients with systemic lupus erythematosus (SLE). METHODS Bone marrow-derived macrophages were isolated from both wild-type and IRF3(-/-) C57BL/6 mice. These cells were stimulated with the Toll-like receptor 3 (TLR-3) agonist poly(I-C), and IL-23p19 cytokine levels were analyzed by enzyme-linked immunosorbent assay. IRF-3 binding to the IL-23p19 gene promoter region in monocytes from patients with SLE and healthy control subjects was analyzed by chromatin immunoprecipitation (ChIP) assay. Luciferase reporter gene assays were performed to identify key drivers of IL-23p19 promoter activity. TANK-binding kinase 1 (TBK-1) protein levels were determined by Western blotting. RESULTS ChIP assays demonstrated that IRF-3 was stably bound to the human IL-23p19 promoter in monocytes; this association increased following TLR-3 stimulation. Patients with SLE demonstrated increased levels of IRF-3 bound to the IL-23p19 promoter compared with control subjects, which correlated with enhanced IL-23p19 production in monocytes from patients with SLE. Investigations of the TLR-3-driven responses in monocytes from patients with SLE revealed that TBK-1, which is critical for regulating IRF-3 activity, was hyperactivated in both resting and TLR-3-stimulated cells. CONCLUSION Our results demonstrate for the first time that patients with SLE display enhanced IL-23p19 expression as a result of hyperactivation of TBK-1, resulting in increased binding of IRF-3 to the promoter. These findings provide novel insights into the molecular pathogenesis of SLE and the potential role for TLR-3 in driving this response.

Estrogen Receptor α Regulates Tripartite Motif–Containing Protein 21 Expression, Contributing to Dysregulated Cytokine Production in Systemic Lupus Erythematosus

To examine the role of 17β‐estradiol in the regulation of the autoantigen tripartite motif–containing protein 21 (TRIM‐21) in patients with systemic lupus erythematosus (SLE).

Estrogen receptor alpha regulates TRIM21 expression, contributing to dysregulated cytokine production in systemic lupus erythematosus.

To examine the role of 17β‐estradiol in the regulation of the autoantigen tripartite motif–containing protein 21 (TRIM‐21) in patients with systemic lupus erythematosus (SLE).

Extractable Nuclear Antigens and SLE: Specificity and Role in Disease Pathogenesis

Publisher Summary Autoantibodies directed against specific nuclear antigens (proteins and DNA) are central to the pathogenesis of systemic lupus erythematosus (SLE). Anti-extractable nuclear antigens (ENA) antibodies are detected to varying degrees in SLE patients. Knowledge regarding the genetic susceptibility towards developing SLE and the etiology of autoantibody development has greatly increased in recent years and it is now widely accepted that defective clearance of apoptotic bodies, viral infection, and molecular mimicry all contribute to the activation of autoreactive B cells and autoantibody production. Anti-ENA antibodies develop a number of years prior to disease onset and, with the exception of Anti-Ro and anti-Sm, are not directly implicated in tissue pathogenesis. The role of the IFN system in the pathophysiology of SLE is well recognized. The anti-ENA immune complexes, by virtue of their being bound to RNA, act as potent stimulators of TLR7 and help drive IFN-α production by plasmacytoid dendritic cells and promote the autoimmune cycle. Recent research findings have suggested that a subset of ENA autoantigens, associated with the Ro/La autoantigen complex, is potentially involved in regulating IFN responses and innate immune detection mechanisms. The possibility that autoantibody generation not only mediates inflammation associated with the recognition of autoantigens but might also result in the inappropriate sequestering of Ro52 and Ro60 is being probed into.

Male lupus: a diagnosis often delayed—a case series and review of the literature

IntroductionSystemic lupus erythematosus (SLE) is an auto-immune disease that is characterised by autoantibody production. Male lupus is rare, apart from at either end of the age spectrum.AimIn this series, we review the histories of six male lupus patients attending our service.ResultsOur patients presented in middle age and tended to develop haematological abnormalities, renal involvement and neurological manifestations which preceded the onset of their skin and joint complaints. Our patients accrued damage rapidly and overall did badly. They tended to respond sub-optimally to standard treatments. These cases highlight the need an increased awareness that male SLE patients present with a wide variety of symptoms, and that they accrue damage quickly. There is a need for timely diagnosis and appropriate initiation of treatment. This may help avoid preventable organ damage and increase the survival of men with SLE.

Limiting cardiovascular risk in Irish rheumatoid arthritis patients

BackgroundPatients with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease and premature death.ObjectivesOur aims were: (1) to assess how thoroughly RA patients were being screened for cardiovascular risk factors in our outpatient population and (2) to evaluate the benefit of introducing a shared care cardiovascular booklet.MethodsWe assessed 80 patients who attend our service with RA. Our initial audit revealed that 80% of patients had not been thoroughly assessed for basic cardiovascular risk. Based on these findings, we created a shared care booklet.ResultsOn re-auditing our service, we found a significant improvement in the assessment of cardiovascular risks.ConclusionThere is currently a low level of screening for cardiovascular risks in busy outpatient clinics. We felt the introduction of a shared care booklet allowed an increased level of screening in our clinics and also acted as a tool for doctor and patient education.

Meticillin-sensitive Staphylococcus aureus costochondritis in a healthy man

Background. A 54-year-old previously healthy white man presented to hospital with fever, right parasternal pain and swelling over the right second and third costochondral joints. The symptoms had developed 1 week earlier.Investigations. Physical examination, white blood cell count, erythrocyte sedimentation rate, C-reactive protein level, blood and urine culture, plain radiography and CT of the chest, 99mTc bone scintigraphy, ultrasound-guided needle aspiration of soft tissue mass, Gram staining and culture of aspirated fluid.Diagnosis. Meticillin-sensitive Staphylococcus aureus costochondritis.Management. CT revealed a 2 × 5 cm soft tissue mass at the posterior aspect of the right second and third costochondral joints. The fluid aspirated contained Gram-positive cocci, and culture revealed the presence of meticillin-sensitive S. aureus. The patient received a 6-week course of flucloxacillin (2 g by intravenous injection every 6 h for 2 weeks, then 1 g orally every 6 h for 4 weeks). He responded well to treatment, and was discharged from hospital.

FRI0378 The Role of Monocyte Subsets in Systemic Lupus Erythematosus Pathogenesis

Background Innate immune cells in particular monocytes (Mo) play a role in the pathogenesis of SLE. Depending on the stimulus they encounter Mo can acquire either a pro (M1) or anti (M2a) inflammatory phenotype. B Lymphocyte Stimulator (BLyS) has been shown to promote Mo survival in health however its effect on Mo subpopulation differentiation in health or SLE, a disease characterised by high levels of circulating BLyS, has not been studied. Objectives To investigate the effect of BLyS on Mo subpopulation differentiation. Methods 25 Patients and controls were recruited. CD14+ Mo subpopulations were analysed by Flow Cytometry using the following markers: M1 (pro-inflammatory) subset = CD14+CD86+HLA-DR+ CD206-CD 163-; M2a (anti-inflammatory) subset = CD14+CD 206+CD163+CD86-HLA-DR-. Serum levels of cytokines associated with M1 Mo (CXCL10) and M2a Mo (CCL17) were assessed by ELISA. Clinical data and disease activity were recorded. Differences between groups were analysed by the Mann-Whitney U test. Results Basally, SLE patients had higher levels of pro-inflammatory M1 Mo (25.2% v 16.3%) and significantly lower levels of anti-inflammatory M2a Mo in comparison to healthy controls (1.8% v 3.4%, p<0.01). Following stimulation with BLyS a significant increase in both the M1 and M2a Mo subpopulations was observed in healthy controls (M1:16.3% v 25.4%, p<0.01; M2a 3.4% v 6%, p<0.01). Similarly SLE patients had enhanced M1 and M2a subpopulations following BLyS stimulation [(M1: 25.2% v 40.4%, p<0.001), (M2a: 1.8% v 6.5%, p<0.05)] such that SLE patients demonstrated significantly higher levels of M1 Mo in comparison to healthy controls following BLyS stimulation (40.4% v 25.4%, p<0.001). Although no absolute difference was observed between patients and controls in the M2a subpopulation following stimulation, when the fold change from baseline was calculated SLE patients had a significant 2 fold increase from baseline in response to BLyS stimulation suggesting BLyS promotes a mixed inflammatory response in SLE. When SLE patients were analysed as per their clinical phenotype a significant difference in % expression of M1 monocytes was demonstrated in SLE patients with evidence of immunological activity (dsDNA +ve) at the time of study visit in response to BLyS stimulation in comparison to those who were dsDNA–ve (63.5% vs 28.2%, p<0.001). BLyS stimulation also appeared to enhance expression of M2a Mo in dsDNA+ve patients, albeit in a non-significant manner (10.3% v 5.9%). Determination of M1 and M2a subset associated cytokines by ELISA confirmed significantly enhanced levels of both subset markers in the serum of SLE patients. Significantly higher levels of CXCL10 were observed in those patients with active disease (493.5pg/ml v 94.2pg/ml, p=0.0045). Regarding clinical involvement CXCL10 levels were higher in those with CNS involvement (649.7pg/ml v 151.7pg/ml, p=0.02) as well as those with evidence of immunological activity. Interestingly CCL17 levels were also higher in patients with active disease (211.7pg/ml v 108.2pg/ml, p<0.0001) with elevated levels also observed in those with both renal involvement (146.8pg/ml v 113.4pg/ml, p=0.046) and serositis (166.8pg/ml v 108.8pg/ml, p=0.039). Conclusions SLE patient Mo demonstrated enhanced pro and anti-inflammatory responses to BLyS stimulation. Enhanced levels of M1 and M2a Mo associated cytokines, which correspond to clinical phenotypes, were also demonstrated in SLE patients. Disclosure of Interest None declared

AB0173 B Lymphocyte Stimulator Promotes Monocyte Activation in Systemic Lupus Erythematosus

Background Systemic Lupus Erythematosus (SLE) involves complex interactions between the innate and adaptive immune systems. Monocytes are increasingly recognised to play a key role in the dysregulated immune response seen in SLE whilst more recently B Lymphocyte Stimulator (BLyS) has been demonstrated to play a key role in the pathogenesis of SLE. Despite the fact that monocytes are one of the key producers of BLyS, the effect of BLyS on monocyte activation in SLE patients has not been determined. Objectives To characterise the activation state of SLE monocytes in their resting state and in response to BLyS. Methods Activation of CD14+ monocytes was characterised in the resting state and following BLyS stimulation in both healthy controls and SLE patients by flow cytometry. Both antigen presenting capacity and co-stimulatory molecule expression were assessed using the following surface markers: CD80, CD86 and HLA-DR. Differences in activation states between groups were examined using the Mann Whitney whilst within group analysis was performed using the Wilcoxon signed-rank test. Spearmans correlation coefficient was also used to assess the relationship between HLA-DR expression and CD80/CD86. Results 25 SLE Patients (as per ACR diagnostic criteria) were recruited. Basal expression of CD80 and HLA-DR was increased on patient monocytes compared to controls (CD80 6.35% v 1.5%, p=0.036, HLA-DR 61.65% v 47.30%, p=0.048). No relationship was observed between disease activity as per SLEDAI and resting SLE patient monocyte function. Interestingly despite their baseline hyper-activated state, following stimulation with BLyS, SLE patients significantly upregulated CD80, CD86 and HLA-DR expression [(CD80 6.35% v 8.4%, p=0.007, CD86 80.8% v 84.6%, p=0.03, HLA-DR 61.65% v 74.95%, p=0.001). In contrast the healthy control volunteers failed to significantly upregulate any of the surface markers following BLyS stimulation indicating that SLE patients monocytes are more responsive to the effects of BLyS. In support of this SLE patients expressed more CD80 and HLA-DR following stimulation than controls (CD 80 8.4% v 2.5%, p=0.0031, HLA-DR 74.95% v 52.90%, p=0.018). When the relationship between CD80/CD86 and HLA-DR surface expression was examined no significant correlation was observed between them in the resting state. However following BLyS stimulation a strong correlation was seen between both CD80/CD86 and HLA-DR expression in SLE patients (CD80 vs HLA-DR:Spearman r =0.64, p=0.005, CD86 vs HLA-DR: Spearman r =0.60, p=0.012) Conclusions Our results suggest that SLE patient monocytes have a hyperactivated phenotype which consequentially results in an enhanced response to BLyS exposure compared to healthy control monocytes. As BLyS plays a significant role in monocyte function in SLE this finding warrants further investigation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2174