Hiroto Nakano

A successful diagnostic case of Pneumocystis pneumonia by the loop-mediated isothermal amplification method in a patient with dermatomyositis

Pneumocystis pneumonia (PCP) can occur in patients with many causes of the immunocompromised state other than human immunodeficiency virus (HIV). It is quite difficult to diagnose PCP without HIV because there is no method for detecting Pneumocystis jirovecii. Thus, non-HIV PCP continues to have high mortality. Recently, loop-mediated isothermal amplification (LAMP) is becoming an established nucleic acid amplification method offering rapid, accurate, and cost-effective diagnosis of infectious diseases. We report a non-HIV PCP case successfully diagnosed by the LAMP method. It was previously reported that PCR in BALF specimens had been the most sensitive method in the diagnosis of PCP without HIV. The LAMP method would be more sensitive than conventional PCR and an effective tool in the early diagnosis of PCP.

Successful treatment of a patient with refractory haemophagocytic syndrome in systemic lupus erythematosus with mycophenolate mofetil

Abstract Haemophagocytic syndrome (HPS) is one of the most severe complications of systemic lupus erythematosus (SLE). Although corticosteroids are usually selected as an initial treatment, some patients are corticosteroid-resistant and require additional immunosuppressants. Here, we report a case of SLE-associated HPS patient who was resistant to prednisolone, calcineurin inhibitors, cyclophosphamide, plasma exchange and infliximab but was successfully treated with mycophenolate mofetil (MMF). MMF could be an alternative treatment for intractable HPS complicated with SLE.

Functional analysis of macrophages in Behçet's disease

Behcets disease (BD) is an inflammatory disorder of unknown cause. The previous genome-wide association studies identified the associations between BD and several loci. Among them, CCR1, MEFV, and IL10 encode genes highly expressed in macrophages, suggesting roles of macrophages in BD.

Dysfunction of TRIM21 in interferon signature of systemic lupus erythematosus

Abstract Objectives: TRIM21 is an E3 ubiquitin ligase for interferon regulatory factors (IRFs) that are involved in innate and acquired immunity. Here, we evaluated the role of TRIM21 in the interferon (IFN) signature of systemic lupus erythematosus (SLE). Methods: Twenty SLE patients and 24 healthy controls were enrolled in this study. We analyzed mRNA expression of TRIM21, type I IFN, and IFN-inducible genes in peripheral blood mononuclear cell (PBMC). The protein levels of IRFs were assessed by Western blotting in PBMCs cultured with or without MG-132. Results: The expression of TRIM21 mRNA and protein was significantly higher in SLE PBMCs as compared to healthy controls. There was a correlation between TRIM21 mRNA expression and SLE activities. In contrast to a negative correlation between mRNA expression level of TRIM21 and those of type I IFNs in healthy controls, we found a positive correlation between them in anti-TRIM21 antibody-positive SLE patients. Neither positive nor negative correlation was observed in the autoantibody-negative SLE patients. Western-blotting analysis revealed impaired ubiquitin-dependent proteasomal degradation of IRFs in SLE PBMCs. Conclusion: Our study showed ubiquitin-dependent proteasomal degradation of IRFs was impaired in anti-TRIM21 antibody-dependent and -independent fashions, leading to amplification of IFN signature in SLE.

GWAS-identified CCR1 and IL10 loci contribute to M1 macrophage-predominant inflammation in Behçet’s disease

BackgroundLow C-C chemokine receptor 1 (CCR1) and interleukin (IL)-10 expression is associated with risk of Behçet’s disease (BD). The objective of the present study was to clarify the pathological roles of CCR1 and IL10 loci identified by previous BD genome-wide association studies (GWASs).MethodsM1 and M2 macrophages (Mφ) were differentiated with granulocyte-macrophage colony-stimulating factor or macrophage colony-stimulating factor (M-CSF) from peripheral monocytes of healthy control subjects (HC) and patients with BD. Expression of CD68 and CD163 was evaluated to test for Mφ polarization. CCR1 and IL-10 messenger RNA (mRNA) and protein expression was compared according to CCR1 and IL10 single-nucleotide polymorphism (SNP) genotypes. The migratory ability of M1 and M2 Mφ toward CCR1 ligand macrophage inflammatory protein (MIP)-1α was compared. The ratio of M1 and M2 Mφ in skin lesions of BD and systemic sclerosis (SSc), which was reported to be M2 Mφ-dominant, was compared. To examine the plasticity of polarized Mφ, the differentiated cells were cultured with either the same or the other culture condition.ResultsPreferential expression of CD163, CCR1, and IL-10 was found in M2 Mφ compared with M1 Mφ. M2 Mφ migrated more sensitively to low concentrations of MIP-1α than M1 Mφ did. BD-derived M1 Mφ showed higher CCR1 surface expression than HC-derived M1 Mφ did. IL10 and CCR1 mRNA expression differences were observed by GWAS-identified SNP genotypes in polarized Mφ. BD skin lesions showed M1 Mφ predominance compared with SSc skin lesions. A plasticity assay revealed that M-CSF restored IL-10 synthesis and reduced IL-6 production by M1 Mφ.ConclusionsThe present study reveals that GWAS-identified SNPs contribute to M1 Mφ-predominant inflammation in BD. Our data also suggest that the skewed Mφ polarization is correctable by immunological intervention.

The predictive prognostic factors for polymyositis/dermatomyositis-associated interstitial lung disease

BackgroundInterstitial lung disease (ILD) is the principal cause of death in polymyositis/dermatomyositis (PM/DM). Here we investigated prognostic factors for death and serious infection in PM/DM-ILD using the multicenter database.MethodsWe retrospectively reviewed baseline demographic, clinical and laboratory findings, treatment regimens and outcomes in patients with PM/DM-ILD. The distribution of ILD lesions was evaluated in four divided lung zones of high-resolution computed tomography images.ResultsOf 116 patients with PM/DM-ILD, 14 died within 6xa0months from the diagnosis. As independent risk factors for early death, extended ILD lesions in upper lung fields (odds ratio (OR) 8.01, pu2009=u20090.016) and hypocapnia (OR 6.85, pu2009=u20090.038) were identified. Serious infection was found in 38 patients, including 11 patients who died ofxa0respiratory or multiple infections. The independent risk factors were high serum KL-6 (OR 3.68, pu2009=u20090.027), high initial dose of prednisolone (PSL) (OR 4.18, pu2009=u20090.013), and combination immunosuppressive therapies (OR 5.51, pu2009<u20090.001).ConclusionThe present study shows the progression of ILD at baseline is the most critical for survival and that infection, especially respiratory infection, is an additive prognostic factor under the potent immunosuppressive treatment.

Dysregulated heme oxygenase-1 low M2-like macrophages augment lupus nephritis via Bach1 induced by type I interferons

BackgroundInnate immunity including macrophages (Mϕ) in lupus nephritis (LN) has been gaining attention, but roles of Mϕ in LN remain uncertain.MethodsImmunohistochemical staining was performed to determine CD68, CD163, heme oxygenase (HO)-1 (a stress-inducible heme-degrading enzyme with anti-inflammatory property), pSTAT1, and CMAF-expressing Mϕ in the glomeruli of patients with LN. Effects of type I interferons on the expression levels of CD163, HO-1, BTB and CNC homology 1 (Bach1; a transcriptional HO-1 repressor), interleukin (IL)-6, and IL-10 by human M2-like Mϕ, which were differentiated in vitro from peripheral monocytes with macrophage colony-stimulating factor, were assessed by RT-PCR and immunocytostaining. Clinical manifestations, anti-double-stranded DNA (anti-dsDNA), and local HO-1 expression were compared in Bach1-deficient and wild-type MRL/lpr mice.ResultsThe number of glomerular M2-like Mϕ correlated with the amounts of proteinuria in patients with LN. Unlike monocyte-derived M2-like Mϕ, HO-1 expression was defective in the majority of glomerular M2-like Mϕ of patients with LN. Stimulation of human M2-like Mϕ with type I interferons led to reduced HO-1 expression and increased Bach1 and IL-6 expression. Bach1-deficient MRL/lpr mice exhibited increased HO-1 expression in kidneys, prolonged survival, reduced urine proteins, and serum blood urea nitrogen levels, but serum anti-dsDNA antibody levels were comparable. Increased expression of CD163 and HO-1 was found in peritoneal Mϕ from Bach1-deficient MRL/lpr mice.ConclusionsOur data suggest that dysregulated M2-like Mϕ play a proinflammatory role in LN. Bach1 is a potential therapeutic target that could restore the anti-inflammatory property of M2 Mϕ.

FRI0419 The predictive prognostic factors for clinical course of polymyositis/dermatomyositis-associated interstitial lung disease

Background Interstitial lung disease (ILD) and concomitant infectious diseases are the predominant causes of death in polymyositis/dermatomyositis (PM/DM). We have already reported that hypocapnea and ILD lesion in upper lung fields are independent prognostic factors. Micro RNA is a non-coding RNA, which has a certain function such as transcriptional regulation. miR-1 has been reported to be associated with myocyte differentiation and to decrease in muscle tissue from patients with inflammatory myopathies. Objectives Here we investigated the association of serum miR-1 level with clinical course of PM/DM-associated ILD (PM/DM-ILD). Methods We retrospectively analyzed clinical baseline, serum miR-1 level, initial therapeutic regimens, total amounts of PSL, clinical outcomes, and episode of infection of patient with PM/DM-ILD who had received initial treatment at six hospitals associated with Yokohama City University from 2003 to 2016. The serum miR-1 level was measured by quantitative real-time PCR. Results One hundred sixteen (PM 22, DM 51, and clinically amyopathic DM 43) patients were included. The mean age was 56±15 years and 83 were female. As initial therapies, oral PSL, methylprednisolone (mPSL) pulse, intravenous cyclophosphamide (IVCY), and oral calcineurin inhibitor therapies were performed in 113 (97%), 80 (69%), 48 (41%) and 80 (69%), respectively. Forty-one patients had a serious infection at 51±38 days from initiation of immunosuppressants and 10 died of infections. Old age, low PaCO2 and albumin, high LDH and KL-6, high score of ILD, high initial dose of PSL, mPSL pulse, IVCY, calcineurin inhibitor and combination therapy were extracted as risk factors for infection by univariate analyses. A multivariate logistic regression analyses revealed that combination therapy (p=0.012, OR 2.83), old age (p=0.024, OR 2.12), high initial dose of PSL (p=0.024, OR 2.69), low albumin (p=0.031, OR 3.56), and low PaCO2 (p=0.038, OR 2.67) were independent risk factors for infection. Serum samples were obtained from total of 14 patients and 13 healthy controls. Serum miR-1 levels in PM/DM-ILD patients before treatment were significantly higher than those in healthy controls (p=0.047). Also serum miR-1 levels were significantly higher in PM/DM-ILD patients with concomitant infectious diseases as compared to patients without infectious diseases (p=0.043). We further divided the PM/DM-ILD cases into two groups by the serum miR-1 level. The higher miR-1 group showed poorer effectiveness of ILD treatment (p=0.040), and lower lymphocyte count (p=0.013) as compared to the lower miR-1 group. Conclusions Appropriate monitoring is important for PM/DM-ILD, especially in older patients with malnutrition or decreased respiratory function. miR-1 can be a new biomarker for predicting treatment response and concomitant infectious diseases during treatment for PM/DM-ILD. References Robert W. Georgantas et al, Inhibition of myogenic microRNAs 1, 133, and 206 by inflammatory cytokines links inflammation and muscle degeneration in adult inflammatory myopathies, Arthritis Rheum, 2014;66:1022–33. Disclosure of Interest None declared

AB0416 Which factors predict the responsiveness to tocilizumab in rheumatoid arthritis? the difference between the usage as the first biologic and as the second biologic

Background Although recent development of a variety of biologics has dramatically improved treatment for rheumatoid arthritis (RA), it is still unclear which biologics is better for use in each patient. Some previous studies have shown the predictive factors for good response (GR) to tocilizumab (TCZ), including low HAQ, high DAS281), low levels of serum soluble IL-6 receptor2), and low numbers of previous use of other biologics3). However, the consensus is not immediately available. Objectives To compare continuation rates (CR) of TCZ by the responsiveness to the therapy and to identify predictive factors for GR to TCZ in RA. Methods Patient with RA who newly started receiving TCZ after April 2008 in our hospital, were included in the study. We collected patient records, medication histories, laboratory data, and clinical parameters longitudinally after starting TCZ. Statistical analyses were performed using the chi-square test, binomial logistic regression analysis, Kaplan-Meier method, and the log-rank test. Results Ninety-two patients were included in the study. The mean age and disease duration at baseline were 60.0±13.5 years and 8.7±8.0 years, respectively. The seroprevalence of the anti-cyclic citrullinated peptide antibody and the rheumatoid factor were 95.4% and 95.7%, respectively. The rate of methotrexate and prednisolone at baseline were 45.7% and 64.1%, respectively. TCZ was administered as the first biologic in 42 patients, and as the second biologic in 33. DAS28(ESR) and CDAI revealed high disease activity at baseline (5.2±1.5 and 25.4±14.1, respectively). The mean CR of all patients was 42.1±4.0 months. The CR was significantly higher in patients who achieved GR in EULAR response criteria at 6 months after starting TCZ than those who did not achieve GR (54.0±6.0 months vs 29.0±5.3 months, p=0.004). Multivariate statistical analysis revealed two predictive factors for achieving GR at 6 months after starting TCZ, the low number of previous use of other biologics and the low CDAI at baseline (p=0.018, odds ratio (OR) =0.386, and p=0.011, OR=0.944, respectively). We divided the patients into two groups, patients using TCZ as the first biologic and patients using it as the second biologic. Univariate statistical analyses revealed low usage rate and dose of prednisolone (PSL) and low serum creatinine level at baseline as the predictive factors for achieving GR in patients using TCZ as the first biologic, and low DAS28(ESR), CDAI and HAQ-DI in the patients using TCZ as the second biologic. By multivariate statistical analysis, we identified the low CDAI as a predictive factor in the patients using TCZ as the second biologic. Conclusions RA patients who achieved GR at 6 months after starting TCZ showed higher CR than the others. This study also suggests that low number of biologics usage and low CDAI at baseline are the predictive factors for GR. The history of biologics usage may be important to identify the predictive factors for GR to TCZ. References Ann Rheum Dis 2011;70:1216–22. Ann Rheum Dis 2014;73:945–7. Pharmacological Research 2016;111:264–71. Disclosure of Interest None declared

THU0287 Parvovirus B19 Infection Mimics Various Rheumatic Diseases: Clinical Features and Frequency of Fulfilling the Criteria for Rheumatoid Arthritis or Systemic Lupus Erythematosus

Background Parvovirus B19 infection in adults has been associated with a variety of rheumatic manifestations and laboratory findings mimicking rheumatic disease. Objectives To explore the clinical features of recent parvovirus B19 infection in adults and investigate the number of patients who fulfill the classification criteria for rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). Methods We performed a retrospective chart review of adult patients with newly-diagnosed parvovirus B19 infection at a community-based hospital in Japan from April 2006 to December 2013. Diagnosis was made with positive serum anti-parvovirus B19 IgM antibody measured by enzyme-linked immunosorbent assay. Results Sixty patients were included (female, 77%; mean age, 39 years) with a mean follow-up of 118 weeks (range, 0-356). Mean disease duration was 34 days (range, 5-316) and mean duration of arthritis was 29 days (range, 7-140). The mean interval between development of the initial manifestation and the onset of arthritis was 4 days (range, 0-19). Arthritis of more than 6 weeks was seen in only one patient. A half of the patients (53%) had a recent history of exposure to people who had clinical manifestations of viral infection. In our study population, predominant signs and symptoms were: arthritis/arthralgia (87%), skin rash (65%), edema (58%), fever (55%), and lymphadenopathy (32%). Regarding arthritis/arthralgia, 18 patients (30%) had physician-diagnosed arthritis, while 34 (57%) had arthralgia alone. Commonly involved joints were in the knee (68.4%), followed by wrist (58%), hand (55%), ankle (55%), and elbow (45%). The most frequent pattern of arthritis/arthralgia was polyarticular (83%). Ten patients (17%) had rash on the cheeks, and 5 others (8%) had characteristic lacy rash on the extremities. The most frequent type of rash was pruritic erythema on the upper and lower limbs. Laboratory findings included anemia (12/60, 20%), lymphocytopenia (41/57, 72%), elevated lactate dehydrogenase (32/55, 58%), positive anti-nuclear antibody (ANA) (30/33, 91%), and hypocomplementemia (13/29, 45%). Autoantibody to DNA and anti-phospholipid antibody were positive in 32% (6/19) and 54% (7/14) of the patients, respectively. Rheumatoid factor (RF) was not detected (0/38), while anti-CCP antibody (ACPA) was detected in 11% (2/18). Persistent infection was diagnosed in two patients. There is no significant difference in baseline characteristics between arthritis group and non-arthritis group. Of all 60 patients, 12 patients fulfilled the 2012 SLICC SLE criteria (six patients met the 1997 revised ACR SLE criteria). Of 18 patients with arthritis, five patients fulfilled the 2010 ACR/EULAR RA criteria (one patient met the 1987 ACR RA criteria). Conclusions Parvovirus B19 infection in adults often presents with acute polyarthritis and skin rash accompanied with lymphocytopenia, hypocomplementemia, and positive ANA. Our study demonstrated that 20% of adult patients with recent parvovirus B19 infection fulfill the SLE criteria and nearly a third of patients with arthritis fulfill the RA criteria. We should consider the possibility of parvovirus B19 infection in the differential diagnosis of SLE or early onset RA. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.3116