Kazuyoshi Kubo

Use of anti-tumor necrosis factor biologics in the treatment of rheumatoid arthritis does not change human T-lymphotropic virus type 1 markers: a case series

Abstract Anti-tumor necrosis factor (anti-TNF) biologics are effective in the treatment of rheumatoid arthritis (RA); however, it is still not clear whether this treatment promotes the development of malignancies such as lymphoma. Human T-lymphotropic virus type 1 (HTLV-1), which is a causative agent of adult T-cell lymphoma (ATL), is prevalent in Japan. Many HTLV-1-positive patients with RA are assumed to exist; however, there have thus far been no reports on the effect of anti-TNF biologics on HTLV-1-positive patients. We analyzed the response to treatment with anti-TNF biologics and change of HTLV-1 markers in two cases of RA. The two cases showed no response based on the European League Against of Rheumatism response criteria 60–96 weeks after administration of anti-TNF biologics (infliximab and etanercept). No signs of ATL were observed and HTLV-1 markers, such as proviral load and clonality of HTLV-1-infected cells, showed no significant change in either of two cases. Therefore, treatment with anti-TNF biologics did not induce activation of HTLV-1, although the effect on RA was not as effective as in HTLV-1-negative patients in this limited study. Further long-term study with a greater number of patients is necessary to clarify the safety and efficacy of anti-TNF biologics in HTLV-1-positive patients with RA.

Treatment with anti–tumor necrosis factor biologic agents in human T lymphotropic virus type I–positive patients with rheumatoid arthritis.

To investigate the response to and safety of anti–tumor necrosis factor (anti‐TNF) therapy in human T lymphotropic virus type I (HTLV‐I)–positive patients with rheumatoid arthritis (RA).

Severe fever with thrombocytopenia syndrome with myocardial dysfunction and encephalopathy: A case report

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease in China, Korea and Japan caused by a novel bunyavirus, SFTS virus (SFTSV). Although central nervous system manifestations are common in SFTS patients, the pathogenesis has not been elucidated; and there are few reports of myocardial dysfunction. Here we report an elderly Japanese patient with reversible myocardial dysfunction and encephalopathy. A previously healthy 65-year-old male engaged in forestry got a tick bite and developed fever and fatigue in 3 days. Three days after onset, he presented to a local hospital where the diagnosis of SFTS with hemophagocytotic syndrome was made. The blood test showed leukopenia and thrombocytopenia as well as elevated levels of alanine aminotransferase and aspartate aminotransferase. Marked hemophagocytosis was found on bone marrow smear. Peripheral blood was positive for SFTSV gene by reverse-transcription polymerase chain reaction. On day 7, the patient was transferred to our hospital. We observed disturbance of consciousness, Kernig sign and myoclonus to face and limbs. Decreased blood flow of whole cerebral cortex was detected by single photon emission computed tomography (SPECT). Chest X-ray revealed cardiomegaly and electrocardiography (ECG) showed abnormal T waves. These data suggested acute encephalopathy and myocardial dysfunction. We treated him with corticosteroid and blood transfusion, which resulted in the complete recovery of the above abnormal symptoms and laboratory data including the findings in SPECT and ECG in about a month. This case demonstrated transient myocardial dysfunction and encephalopathy can occur in addition to typical clinical manifestation of SFTS.

Evaluation of Line Immunoassay to Detect HTLV-1 Infection in an Endemic Area, Southwestern Japan; Comparison with Polymerase Chain Reaction and Western Blot.

BACKGROUND Human T-lymphotropic virus type 1 (HTLV-1) has been recognized as a cause of adult T-cell leukemia/lymphoma, HTLV-1-associated myelopathy/tropical spastic paraparesis, and HTLV-1-associated uveitis. HTLV-1 infection is normally detected by screening for HTLV-1 antibodies, and positive samples are confirmed by Western blot (WB). However, WB fails to confirm some samples that were positive for HTLV-1 antibodies on screening. Line immunoassay (LIA) is commonly used in Europe and Brazil, but not in Japan. Therefore, we evaluated the performance of LIA as a method of confirming HTLV-1 antibodies using samples in Japan. METHODS LIA was compared with polymerase chain reaction (PCR) and WB using 50 negative and 70 positive samples tested by chemiluminescent enzyme immunoassay (CLEIA) in Miyazaki, Japan, an HTLV-1 endemic area. LIA (INNO-LIA HTLVI/II Score) and WB (Problot HTLV-I) were performed according to the manufacturers instructions. Real-time PCR for HTLV-1 pX region was performed using DNA derived from white blood cells. The samples that tested negative by real-time PCR were further tested by nested PCR. RESULTS All 50 CLEIA negative samples were determined to be negative by LIA and PCR. Of the 70 positive samples, 66 tested positive by both of LIA and PCR. Three samples tested negative by LIA and PCR, and the remaining sample (PCR negative) showed non-specific staining in LIA and WB. WB showed more indeterminate results than LIA. Gp21 antibody in LIA demonstrated a high ability to discriminate between positive and negative PCR results. Furthermore, the degree of gp21 antibody reaction by LIA showed correlation with HTLV-1 proviral loads (PVLs). CONCLUSIONS Our results indicate that LIA performs well in confirming HTLV-1 seropositivity by showing a low incidence of indeterminate results and good agreement with PCR using samples in Japan, although the number of samples tested was small. In addition, semi-quantitative antibody titer to gp21 correlated well with HTLV-1 PVLs. Further study including larger samples is necessary to determine the positioning of LIA for HTLV-1 detection in Japan.

Possible Case of Novel Spotted Fever Group Rickettsiosis in TravelerReturning to Japan from India

A 60-year-old woman experienced fever, headache, rash, and altered vision after returning to Japan from India. Testing detected elevated antibody titers to spotted fever group rickettsia; PCR on blood yielded positive results for the rickettsial outer membrane protein A gene. We isolated a unique rickettsial agent and performed a full-genome analysis.

Remission of chronic type ATL in a patient with rheumatoid arthritis after withdrawing methotrexate and infliximab combination therapy: a case report

Abstract A 70-year-old Japanese female was diagnosed with seropositive rheumatoid arthritis (RA) in January 2008. She had high disease activity and was treated with prednisolone, methotrexate (MTX) and infliximab (IFX). She was found to be positive for human T-lymphotropic virus type 1 (HTLV-1) antibody in 2012, and her HTLV-1 proviral DNA load (PVL) was as high as 5.82 copies per 100 white blood cells (WBCs). In 2014, she complained of fever and showed elevated soluble IL-2 receptors (sIL-2R) and WBCs. Abnormal lymphocytes with convoluted nuclei were found on blood smear analysis (13% of WBCs). She was negative for lymphadenopathy, skin lesion and organomegaly. She was diagnosed with chronic type adult T-cell leukaemia-lymphoma (ATL), and treatment with IFX and MTX was discontinued. Abnormal lymphocytes disappeared and sIL-2R level decreased a few months later. ATL did not relapse for more than 2 years. This case emphasises the need for careful observation in HTLV-1 positive patients with RA, especially in patients with high PVL. In addition, there is a possibility that prompt withdraw of biologics and MTX may contribute to the spontaneous remission of ATL.

The time-sequential changes of risk factors for adult T-cell leukemia development in human T-cell leukemia virus-positive patients with rheumatoid arthritis: a retrospective cohort study

Abstract Objective: This study aimed to investigate the time-sequential changes of risk factors for adult T-cell leukemia (ATL) development in human T-cell leukemia virus type 1 (HTLV-1)-positive rheumatoid arthritis (RA) patients. Methods: HTLV-1 infection was screened using particle agglutination assay and confirmed via western blotting in 365 RA patients. Twenty-three HTLV-1-positive RA patients were included in the study cohort. Blood samples were obtained from these patients at each observation time point. The values of HTLV-1 proviral load (PVL) and serum soluble IL-2 receptor (sIL2-R), which are risk factors for ATL development, were measured using real-time PCR and enzyme immunoassay, respectively. Results: The study cohort comprised 79 person-years. The median HTLV-1 PVL and sIL2-R values of the HTLV-1-positive RA patients were 0.44 copies per 100 white blood cells (WBCs) and 406 U/mL, respectively. Three HTLV-1-positive RA patients showed a high PVL value. No remarkable changes were observed in the PVL and sIL2-R values during the observation period. However, one elderly HTLV-1-positive RA patient who had a high PVL value developed ATL during treatment with methotrexate and infliximab. Conclusion: A thorough clinical assessment of the risk factors for ATL development may be necessary in daily clinical practice for RA patients in HTLV-1-endemic areas in Japan.

Leukocytapheresis in rheumatoid arthritis

In this article, we discussed leukocytapheresis (LCAP) for rheumatoid arthritis (RA). Recently, a simple and practical on-line continuous LACP system has been developed. It is equipped with a direct hemoperfusion column (Cellsorba®, Asahikasei Medical Co., Ltd.) packed with fine-diameter polyester fibers, which are commonly used to adsorb white blood cells to prevent a graft-versus-host reaction during blood transfusion. Clinical trials revealed that LCAP is a effective and safe therapy for patients with drug-resistant RA or RA complicated with vasculitis. Because the procedure is simple and requires no plasma substitutes and the volume needed for extracorporeal circulation is less than that for other plasmapheresis, LCAP might be accepted as an optional therapeutic modality for active RA that was refractory to conventional drug therapy including biological agents. The mechanism of the efficiency of LCAP on RA is unclear. LCAP may cause a reduction of activated T cells from affected joints, down-regulation of Pgp on helper T cells and restoration of Treg function, and that may modify the abnormal cytokine balance. These findings may explain some of the mechanisms by which the articular symptoms are improved by LCAP.

AB0021 Human T cell leukemia virus type 1 (HTLV-1) exacerbates rheumatoid arthritis; exosomes and IFN-GAMMA derived from HTLV-1 infected cells enhance the inflammatory response of rheumatoid arthritis synovial fibroblasts via pattern recognition receptor, RIG-I

Background Human T cell leukemia type 1 (HTLV-1) positive rheumatoid arthritis (RA) patients show severe inflammatory state and resistance to anti-rheumatic therapy, including biologic agents (1). HTLV-1 infected T cells was increased in the synovial fluid and tissue from an HTLV-1 positive RA patients (2). However the mechanism of worsening RA by HTLV-1 infection remains unclear. We focused on the role of HTLV-1 infected T cells as a key player in the exacerbation of RA. Objectives To clarify the role of HTLV-1 infected T cells in the pathogenesis of RA. We investigate inflammatory mediators derived from HTLV-1 infected cells. Methods Peripheral blood mononuclear cells (PBMCs) were collected from asymptomatic HTLV-1 carriers (AC) (n=5) and healthy subjects (HS) (n=5). Rheumatoid arthritis synovial fibroblasts (RASFs) were co-cultured with PBMCs for 5 days. Cytokine profiles of supernatants were analyzed by multiplex. Exosomes were isolated and purified from cultured medium of HTLV-1 infected cell line (MT2). RASF was cultured with MT2 derived exosomes with and without IFN-gamma for 24hours. Total RNA was extracted using TRIZOL method. The expression of RIG-I, IL-6, CXCL10, and CCL5 mRNA in RASF was measured using real-time quantitative PCR. The expression of pattern recognition receptor, RIG-I was determined by immune blotting. Silencing of RIG-I in RASF was performed by transfection of siRNA against RIG-I. Results The levels of cytokine, including IFN-gamma, IL-2, IL-9, IL-13, IL-6, and CCL20, were higher in supernatants co-cultured with HTLV-1 positive PBMCs than in those of negative PBMC (p<0.05). The expression of CXCL10 and IL-6 mRNA was increased in RASF co-cultured with HTLV-1 positive PBMCs compared to those of negative PBMCs. IFN-gamma is well known to be an important cytokine in the pathogenesis of HTLV-1 associated inflammatory diseases. IFN-gamma induced the expression of IL-6, CCL5, and CXCL10 mRNA in RASF. HTLV-1 infected cell line, MT2, autonomously released a large amount of exosomes which contain nucleic acids such as RNA and DNA. MT2 derived exosomes significantly enhanced the expression of CXCL10 mRNA, but not IL-6 and CCL5, in RASF activated by IFN-gamma. Therefore, we hypothesized that exosomes play the role of ligand for pattern recognition receptors. IFN-gamma increased the expression of RIG-I protein in RASF in a dose-dependent manner. The expression of RIG-I protein also increased in RASF co-cultured with HTLV-1 positive PBMCs compared to those of negative PBMCs. Finally, the silencing of RIG-I suppressed the expression of CXCL10 in RASF induced by co-stimulation of both exosomes and IFN-gamma. Conclusions It is possible that HTLV-1 infected T cells exacerbate the inflammatory responses of RASFs. Exosomes derived from HTLV-1 infected cells enhance the expression of CXCL10 in RASF induced by IFN-gamma via pattern recognition receptor, RIG-I. References Umekita K, et al. Arthritis Care Res (Hoboken). 2014 May;66(5):788–92. Yakova M, et al. Retrovirology. 2005 Feb 1;2:4. Disclosure of Interest None declared

AB0589 Hypercoagulable State Might Be Induced by Alveolar-Endothelial Damages in Interstitial Lung Disease Associated with Polymyositis/dermatomyositis

Background Polymyositis and dermatomyositis (PM/DM) are often complicated by interstitial lung diseases (ILD), which is an important cause of death. It has been reported that endothelial damages are likely to exist in PM/DM patients with ILD (PM/DM-ILD). Endothelial damages and oxidative stress induced hypercoagulable state in many connective tissue diseases (CTD) such as rheumatoid arthritis, systemic lupus erythematosus and systemic scleroderma. Recent evidence suggested that anticoagulation therapies might contribute to improve the disease activity of pneumonia related to CTDs. Objectives The purpose of this study was to clarify the association between the disease activity of ILD and blood coagulation disorders in patients with PM/DM. Methods This study is retrospective observation study. The medical records of 22 patients who were diagnosed as having PM/DM admitted to our hospital from April 2012 to March 2015 were reviewed in present study (median age: 50.5, female ratio: 81.8%). Diagnosis of ILD was evaluated by chest high-resolution CT. We reviewed the laboratory findings and autoantibody profile associated with PM/DM. Results Eighteen of 22 (81.8%) patients with PM/DM were diagnosed as having ILD. Autoantibodies associated with PM/DM were evaluated in 14 patients among 18 patients with PM/DM-ILD. Anti-aminoacyl-tRNA synthetases (ARS) and anti-MDA5 antibody was positive in 8/14 patients (57%) and 4/14 patients (29%), respectively. Anti-Jo-1 antibody was detected in 3 patients (38%), anti-PL7 in 3 patients (38%), anti-OJ in one patient (12%), and anti-EJ in one patient (12%) in 8 patients with anti-ARS antibody positive PM/DM-ILD. The levels of creatinine kinase (CK) in anti-ARS antibody positive PM/DM-ILD patients was higher than those in anti-ARS antibody negative PM/DM-ILD patients (median CK 2464 v.s 106 IU/ml, p=0.01). The levels of serum KL-6 and plasma D-dimer in anti-ARS antibody positive PM/DM-ILD patients tended to be higher than those in anti-ARS antibody negative PM/DM-ILD patients (median KL-6 691 v.s 489 IU/ml, D-dimer 2.57 v.s 1.96 ug/ml). Additionally, there is significantly positive correlation in the levels of between serum KL-6 and plasma D-dimer (R=0.58, p=0.0008). However, there is no correlation between the levels of serum KL-6 and blood coagulation tests, such as prothrombin time (%) and activated thromboplastin time. Conclusions These results suggest that anti-ARS antibody, especially anti-Jo-1 and anti-PL7, seems to be associated with the severity of muscular manifestation and alveolar-endothelial damages. The level of plasma D-dimer reflects the disease activity of ILD in patients with PM/DM. The hypercoagulable state might be induced by alveolar-endothelial damages and oxidative stress in PM/DM-ILD. Acknowledgement We thank Ms. Yuki Kaseda for excellent technical assistance. Disclosure of Interest None declared