Huseyin T. E. Ozer

Identification of multiple genetic susceptibility loci in Takayasu arteritis

Takayasu arteritis is a rare inflammatory disease of large arteries. The etiology of Takayasu arteritis remains poorly understood, but genetic contribution to the disease pathogenesis is supported by the genetic association with HLA-B*52. We genotyped ~200,000 genetic variants in two ethnically divergent Takayasu arteritis cohorts from Turkey and North America by using a custom-designed genotyping platform (Immunochip). Additional genetic variants and the classical HLA alleles were imputed and analyzed. We identified and confirmed two independent susceptibility loci within the HLA region (r(2) < 0.2): HLA-B/MICA (rs12524487, OR = 3.29, p = 5.57 × 10(-16)) and HLA-DQB1/HLA-DRB1 (rs113452171, OR = 2.34, p = 3.74 × 10(-9); and rs189754752, OR = 2.47, p = 4.22 × 10(-9)). In addition, we identified and confirmed a genetic association between Takayasu arteritis and the FCGR2A/FCGR3A locus on chromosome 1 (rs10919543, OR = 1.81, p = 5.89 × 10(-12)). The risk allele in this locus results in increased mRNA expression of FCGR2A. We also established the genetic association between IL12B and Takayasu arteritis (rs56167332, OR = 1.54, p = 2.18 × 10(-8)).

Analysis of CD28 and CTLA‐4 gene polymorphisms in Turkish patients with Behcet's disease

In this study we aimed to investigate IVS3 +17T/C single nucleotide polymorphism (SNP) of CD28 gene, +49A/G and −318C/T SNPs of CTLA‐4 gene in patients with Behçets disease (BD) and their potential association to the main clinical features of the disease. These polymorphisms were investigated in a Turkish population of 123 patients with BD and 179 healthy controls, by using PCR‐RFLP technique. HLA‐B*51 genotype was also studied in both groups by using PCR‐SSP. The frequency of IVS3 +17TC genotype of the CD28 gene was significantly increased in BD patients compared to controls (43.6% vs. 31.2%, OR = 1.663, 95% CI = 1.033–2.679, P = 0.039). CTLA‐4 +49GG genotype frequency was found to be significantly lower in patients with BD than those of healthy controls (4% vs. 10.6%, OR = 0.357, 95% CI = 0.130–0.983, P = 0.05). Genotype and allele frequencies of the CTLA‐4–318C/T polymorphism between the BD and healthy control groups were not significantly different (12.2% vs. 10.6%, OR = 1.170, 95% CI = 0.570–2.402, P = 0.713). There were no associations between the studied polymorphisms and the main clinical features of BD. The frequencies of HLA‐B*51 were 60.3% and 30.7% in BD and control groups, respectively (OR = 3.429, 95% CI = 2.115–5.559, P = 0.0001). Association between HLA‐B*51 and each studied polymorphism did not reach to significant levels (OR = 0.479, 95% CI = 0.228–1.004, P = 0.064 for CD28 IVS3 +17TT genotype; OR = 2.180, 95% CI = 1.025–4.639, P = 0.061 for TC genotype; OR = 1.570, 95% CI = 0.870–2.836, P = 0.146 for C allele). These results may suggest that CD28 IVS3 +17TC genotype may be a risk factor for the development of BD, on the contrary CTLA‐4 +49GG genotype may be protective in the studied Turkish population.

Takayasu's arteritis is associated with HLA-B*52, but not with HLA-B*51, in Turkey

IntroductionHLA-B*51 and HLA-B*52 are two close human leukocyte antigen (HLA) allele groups with minor amino acid differences. However, they are associated with two different vasculitides (HLA-B*51 in Behçets disease and HLA-B*52 in Takayasus arteritis (TAK)) and with major clinical and immunological differences. In this study, we aimed to screen a large cohort of TAK patients from Turkey for the presence of HLA-B*51 and HLA-B*52 as susceptibility and severity factors.MethodsTAK patients (n = 330) followed at a total of 15 centers were included in the study. The mean age of the patients was 37.8 years, and 86% were women. DNA samples from the patients and healthy controls (HC; n = 210) were isolated, and the presence of HLA-B*51 or HLA-B*52 was screened for by using PCR with sequence-specific primers.ResultsWe found a significant association of HLA-B*52 with TAK (20.9% vs HC = 6.7%, P = 0.000, OR = 3.7, 95% CI = 2.02 to 6.77). The distribution of HLA-B*51 did not differ between TAK patients and HCs (22.7% vs 24.8%, OR = 0.9, 95% CI = 0.60 to 1.34). The presence of HLA-B*52 decreased in late-onset patients (> 40 years of age; 12.0%, P = 0.024, OR = 0.43, 95% CI = 0.20 to 0.91). Patients with angiographic type I disease with limited aortic involvement also had a lower presence of HLA-B*52 compared to those with all other disease subtypes (13.1% vs 26%, P = 0.005, OR = 0.43, 95% CI = 0.23 to 0.78).ConclusionsIn this study, the previously reported association of TAK with HLA-B*52 in other populations was confirmed in patients from Turkey. The functional relevance of HLA-B*52 in TAK pathogenesis needs to be explored further.

The association between cervical rib and sacralization.

Study Design. After determining the normal reference values for the length of the transverse processes of the seventh cervical vertebra, the association between the presence of cervical rib and sacralization was investigated. Objective. To determine the length of cervical rib and search for any association between cervical rib and sacralization. Summary of Background Data. Both cervical ribs and sacralization have been noted in some patients in the authors’ clinical practice. Methods. The cervical rib is a supernumerary rib arising from a cervical vertebra, or it might be simply an elongation of the transverse process of the seventh cervical vertebra. However, there is no consensus about a specified length of this process. For reference values, anteroposterior cervical radiographs of 210 normal individuals (112 male, 98 female, mean age 33.9 ± 10.1 years, range 19–61 years) were taken, and elongation of the transverse processes beyond 2 standard deviations (30 mm) was considered as cervical rib. In the guide of the reference values, 324 outpatients (165 male, 159 female, mean age 42.0 ± 14.6 years, range 17–85 years), having cervical ribs or sacralization detected by plain radiographs, were taken as the study group. As control 729 volunteers (364 male, 365 female, mean age 41.7 ± 14.3 years, range 15–76 years) were studied. Results. In 1053 patients, of 471 patients having cervical ribs, 345 (73.2%) had also sacralization; of 536 patients with sacralization, 345 (64.4%) also had cervical ribs. Significant associations were found between cervical rib with or without articulation and sacralization [&khgr;2 = 52.284, P < 0.001, odds ratio 5.097 (3.156–8.234); &khgr;2 = 139.473, P < 0.001, odds ratio 5.204 (3.922–6.905), respectively]. Conclusion. Presence of cervical rib might be a clue to the existence of sacralization or vice versa. In patients with cervical or lumbar pain, this association may be helpful for differential diagnosis before applying sophisticated diagnostic techniques.

The Turkish version of the Bath Ankylosing Spondylitis Functional Index: reliability and validity

The purpose of this study was to investigate the reliability and validity of the Turkish version of the Bath Ankylosing Spondylitis (AS) Functional Index (BASFI). The Turkish version of the BASFI was obtained after a process of translation and back-translation. Eighty-one consecutive patients meeting the 1984 New York criteria for AS were enrolled. Patients were evaluated and requested to complete the questionnaire at days 1 and 2 and on a third occasion between days 15–90. Reliability, reproducibility, validity and sensitivity to change of the Turkish version of the index were assessed. Each score correlated closely with the index score, with coefficients between 0.727 and 0.844. Reliability analysis showed a Cronbach’s alpha score of 0.926. Correlations were found between all items of the BASFI and Schober’s test (r=−0.258 to −0.531, p<0.001–0.05), occiput-to-wall distance (r=0.284 and 0.589, p<0.001–0.05), and finger-to-floor distance (r=0.334 to 0.613, p<0.001–0.01). The total index score was correlated with the number of nocturnal awakenings (r=0.515, p<0.001), Schober’s test (r=−0.444, p<0.001), finger-to-floor distance (r=0.567, p<0.001), occiput-to-wall distance (r=0.535, p<0.001), chest expansion (r=−0.403, p<0.001), and the Dougados articular index (r=0.371, p<0.01). A good correlation was found between day 0 and 1 BASFI indices (r=0.765–0.917, p<0.001), showing good reproducibility of the index. The Turkish version of the BASFI showed reliability, reproducibility, and validity, confirming its utility in the research of AS in Turkey. However, sensitivity to changes due to drug therapy and/or rehabilitation remains to be determined.

Identification of Susceptibility Loci in IL6, RPS9/LILRB3, and an Intergenic Locus on Chromosome 21q22 in Takayasu Arteritis in a Genome-Wide Association Study

Takayasu arteritis is a rare large vessel vasculitis with incompletely understood etiology. This study was undertaken to perform the first unbiased genome‐wide association analysis of Takayasu arteritis.

PTPN22 gene polymorphism in Takayasu's arteritis

OBJECTIVE Takayasus arteritis (TA) is a chronic, rare granulomatous panarteritis of unknown aetiology involving mainly the aorta and its major branches. In this study, genetic susceptibility to TA has been investigated by screening the functional single nucleotide polymorphism (SNP) of PTPN22 gene encoding the lymphoid-specific protein tyrosine phosphatase. METHODS Totally, 181 patients with TA and 177 healthy controls are genotyped by PCR-RFLP method for the SNP rs2476601 (A/G) of PTPN22 gene. Polymorphic region was amplified by PCR and digested with Xcm I enzyme. RESULTS Detected frequencies of heterozygous genotype (AG) were 5.1% (9/177) in control group and 3.8% (7/181) in TA group (P = 0.61, odds ratio: 0.75, 95% CI: 0.3, 2.0). No association with angiographic type, vascular involvement or prognosis of TA was observed either. CONCLUSION The distribution of PTPN22 polymorphism did not reveal any association with TA in Turkey.

Vasculitis Induced by Zafirlukast Therapy

Abstract Zafirlukast is a leukotriene inhibitor that has recently been approved for the prophylaxis of asthma. Although this new product has been well accepted because of its convenient dosing and relatively few side effects, several cases of Churg–Strauss syndrome have been reported to be associated with its use. In this paper we describe the case of a 54-year-old white man with no history of corticosteroid therapy in whom leukocytoclastic vasculitis, hepatitis and eosinophilia developed while he was on zafirlukast therapy for mild asthma.

Serum RANTES, MIP-1α, and MCP-1 levels in Behçet’s disease

Behçet’s disease (BD) is a multisystemic vasculitis of unknown etiology characterized by oral and genital ulceration and eye, skin, joint, gastrointestinal, and neurological manifestations. Besides elevated levels of tumor necrosis factor alpha (TNF-a) in sera of patients with BD [1], increased TNF-a and interleukin (IL)-1 production has been shown in lipopolysaccharide-stimulated peripheral blood monocytes [2]. Additionally, TNF-a and IL-1b mRNA have been shown to be increased in attack-free periods in patients with familial Mediterranean fever (FMF) [3]. It is generally accepted that certain chemokines such as regulated-on-expression, normal-T-cell-expressedand-secreted (RANTES), macrophage inflammatory protein (MIP)-1, and monocyte chemotactic protein (MCP)-1 are stimulated in response to more proximal mediators such as TNF-a and IL-1 [4]. Elevated plasma and whole blood MCP-1 levels have been reported in patients with BD, regardless of activity [5]. To gain information about the role of chemokines in the inflammation of patients with BD and their relation to disease activity, serum levels of the CC chemokines RANTES, MIP-1a, and MCP-1 were measured. Patients with familial Mediterranean fever (FMF) and healthy study participants were taken as controls. Serum samples from 21 patients with BD (mean age 38.95±1.6 years, ten females and 11 males, 11 active and ten inactive) meeting the criteria of the International Study Group for BD were taken. Except for two patients from the active and inactive disease groups, all BD patients were on colchicine (0.5–1.5 mg daily). Those having new onset or exacerbation of at least one of the clinical manifestations including genital ulcer, uveitis, arthritis, erythema nodosum, thrombophlebitis, and central nervous system or gastrointestinal disease were considered as active. Patients using corticosteroids or immunosuppressives were excluded. Twenty-seven patients with FMF meeting Tel Hashomer criteria for the disease (mean age 34.3± 10.2 years, 14 females and 13 males, 13 during attack and 14 in attack-free periods) and 27 healthy participants (mean age 37±6.6 years, 13 females and 14 males) were taken as the control groups. The study was conducted at the rheumatology outpatient clinic of Cukurova University Hospital in Adana, Turkey. Written informed consent was taken from all patients, and the study was approved by the institutional review board. It was performed in compliance with the Helsinki Declaration. RANTES, MIP-1a, and MCP-1 levels were measured from the serum samples by enzyme-linked immunosorbent assay (ELISA) at one occasion by the same person. Commercial human ELISA kits (Endogen, USA) were used for each chemokine measurement. Assay ranges were 51.2–2000 pg/ml, 0–1000 pg/ml, and 51–2000 pg/ ml for RANTES, MIP-1a, and MCP-1, respectively. Four exon-10 mutations of the MEFV gene (M694V, M680I, V726A, and M694I) were sought by amplification refractory mutation [6]. Kruskal-Wallis analysis of variance (ANOVA) was used for comparison among three groups, and the Mann-Whitney-U test was used for comparing two groups. Correlation analyses were done by nonparametric Spearman’s correlation test. Mean serum MIP-1a levels were found to differ among the groups (P=0.012, ANOVA). The level in BD (mean±SEM 126.80±36.10 pg/ml) was significantly higher (P=0.005) than in the controls (80.93±43.38 pg/ ml) but not significantly different from that of the FMF patients (78.94±29.24 pg/ml). Mean MIP-1a levels of H. T. E. Ozer (&) Æ E. Erken Æ R. Gunesacar Rheumatology-Immunology Division, Cukurova University Faculty of Medicine, Adana, 01330 Turkey E-mail: teozer@cu.edu.tr Tel.: +90-533-7178442 Fax: +90-322-3386721

Assessment of Patients with Takayasu Arteritis in Routine Practice with Indian Takayasu Clinical Activity Score

Objective. To assess the Indian Takayasu Clinical Activity Score (ITAS2010) in followup of Takayasu arteritis (TA). Methods. ITAS2010 forms were filled in prospectively (n = 144). Clinical activity was assessed with physician’s global assessment (PGA) and criteria defined by Kerr, et al. Results. ITAS2010 was significantly higher in patients with active disease. Total agreement between ITAS2010 and PGA was 66.4%, and between ITAS2010 and Kerr, et al was 82.8%. During followup, 14 of 15 patients showing vascular progression with imaging were categorized as having inactive disease according to ITAS2010. Conclusion. ITAS2010 was discriminatory for activity during the followup, but the agreement between PGA and ITAS2010 was moderate. Future work should include the incorporation of advanced vascular imaging and demonstration of ITAS2010 as a scalable measure and not simply a dichotomous measure of activity/flare versus remission.