Kentaro Noda

Clinical Significance of Serum Levels of Vascular Endothelial Growth Factor, Angiopoietin-1, and Angiopoietin-2 in Patients with Rheumatoid Arthritis

Objective. To evaluate the clinical significance of serum levels of vascular endothelial growth factor (VEGF), angiopoietin-1 (Ang-1), and angiopoietin-2 (Ang-2) in patients with rheumatoid arthritis (RA). Methods. The subjects were 70 patients with RA. Serum VEGF, Ang-1, and Ang-2 levels were determined by ELISA. As indices of disease activity, serum levels of C-reactive protein (CRP) and matrix metalloprotease (MMP)-3 were examined, and the 28-joint count Disease Activity Score (DAS28)-CRP was calculated. Power Doppler ultrasonography was performed in the bilateral wrists, elbows, shoulders, knees and ankles. The synovial blood flow signals were scored using a 3-grade scale (0–2), and the total of the scores in the 10 joints was regarded as the total signal score (TSS). Results. Serum VEGF level showed significant correlations with serum CRP and MMP-3 levels, DAS28-CRP, and TSS. Serum Ang-1 level showed significant correlations with serum MMP-3 level and DAS28-CRP. Serum Ang-2 level showed significant correlations with serum CRP level and TSS. Conclusion. The serum VEGF level is important as an index of the activity of RA based on angiogenesis and a prognostic factor regarding joint destruction. Serum Ang-1 level may be useful as an index of sustained arthritis based on the maintenance of newly formed vessels. Serum Ang-2 level may reflect a state of marked angiogenesis.

Fasciitis as a common lesion of dermatomyositis, demonstrated early after disease onset by en bloc biopsy combined with magnetic resonance imaging.

OBJECTIVE To investigate whether fasciitis is histopathologically demonstrable in patients with dermatomyositis (DM), and to analyze the process of inflammatory progression in myopathy accompanying DM. METHODS STIR or fat-suppressed T2-weighted magnetic resonance imaging (MRI) and en bloc biopsy were performed in 14 patients with newly diagnosed adult-onset DM. The severity of inflammatory cell infiltration around the fascial and intramuscular small blood vessels was evaluated using the total vascular inflammation score (TVIS). RESULTS In all patients, MRI revealed abnormal hyperintensity in the fascia and in marginal sites of the muscle, predominantly over central sites. En bloc biopsy revealed the presence of fasciitis in most of the patients, as shown by inflammatory infiltrates around the fascial small blood vessels. In those patients who underwent en bloc biopsy earlier than 2 months after the appearance of muscle symptoms, the TVIS of the fascia was significantly higher than the TVIS of the muscle. In contrast, in those patients who underwent en bloc biopsy >2 months after muscle symptom onset, the TVIS of the fascia did not differ significantly from the TVIS of the muscle. CONCLUSION Fasciitis was histopathologically demonstrated in patients with newly diagnosed adult-onset DM as early as 2 months after the onset of muscle symptoms. These results indicate that fasciitis is a common lesion of DM and suggest that the fascial microvasculature is the primary site of inflammatory cell infiltration in DM. Fasciitis may contribute to muscle symptoms in patients with DM without myositis.

The effect of endostatin evaluated in an experimental animal model of collagen-induced arthritis.

Objective: To investigate the arthritis‐inhibiting effect of endostatin, a potent angiogenesis inhibitor, on type II collagen‐induced arthritis (CIA). Methods: In an experimental system of prophylactic administration, endostatin was administered once daily at 1 mg/kg/day or 10 mg/kg/day for 2 weeks from before the onset of arthritis. In the experimental system of therapeutic administration, mice with an arthritis score of 1 to 3 were administered endostatin once daily at 10 mg/kg. In the experimental system of continuous administration, endostatin was administered using an osmotic pump capable of continuously administering a calculated dose of 1 mg/kg/day for 2 weeks. Results: Arthritis scores were lower in a dose‐dependent manner in the prophylactic administration group than in the control group. Arthritis scores were lower in the therapeutic administration group than in the control group. Compared with the once‐daily dosage regimen, the administration of endostatin by an osmotic pump achieved a similar arthritis‐inhibiting effect at one‐tenth of the dose. Conclusion: Both prophylactic and therapeutic administration of endostatin inhibited type II CIA in mice. The administration method using an osmotic pump is useful.

Brief Report: Power Doppler Ultrasonography for Detection of Increased Vascularity in the Fascia: A Potential Early Diagnostic Tool in Fasciitis of Dermatomyositis

We previously demonstrated that fasciitis is a common lesion of dermatomyositis (DM) that is detectable early after disease onset by en bloc muscle biopsy combined with magnetic resonance imaging (MRI). Power Doppler ultrasonography (PDUS) is a useful method for detection of inflammation and vascularity in rheumatic diseases. We undertook this study to determine whether fasciitis was detectable by PDUS in patients with DM.

Myalgia in Patients with Dermatomyositis and Polymyositis Is Attributable to Fasciitis Rather Than Myositis: A Retrospective Study of 32 Patients who Underwent Histopathological Examinations

Objective. To determine the association between fasciitis and the clinical variables in patients with dermatomyositis (DM) and polymyositis (PM). Methods. We retrospectively reviewed the medical records of 32 patients (24 DM, 8 PM) with newly diagnosed DM and PM and in whom fascia and muscle specimens were histopathologically examined. The relationship between fasciitis and the clinical variables was statistically analyzed. These included age, sex, myalgia, muscle weakness, creatine kinase (CK) and aldolase activities, anti-Jo1 antibody, interstitial lung disease, and malignancy. Results. Twenty (62.5%) of the 32 patients who underwent the histopathological examination of a fascia specimen had fasciitis, including 18 (75%) of 24 patients with DM and 2 (25%) of 8 patients with PM. The frequency of fasciitis was significantly higher among the patients with DM than among the patients with PM (p < 0.05). Histopathologically, fasciitis in PM was very mild in comparison to that in DM. The frequency of myalgia in patients with fasciitis was significantly higher than that in patients without fasciitis (p < 0.05). However, myalgia was not associated with myositis. There were no significant differences in the patients with and without fasciitis in age, sex, manual muscle test 8 scores, CK or aldolase activities, or the presence of anti-Jo1 antibodies and malignancy. Conclusion. The frequency of fasciitis was significantly higher among patients with DM than among those with PM. Fasciitis, rather than myositis, was associated with myalgia.

Elevation of Bombina variegata peptide 8 in mice with collagen-induced arthritis

BackgroundBombina variegate peptide 8 (Bv8) is a small protein secreted by frog skin. Recently it has been shown to contribute to tumor angiogenesis in mouse model. The purpose of this study was to investigate Bv8 in mice with type II collagen-induced arthritis (CIA).MethodsWe induced CIA in male DBA/1J mice. The severity of arthritis was evaluated based on an arthritis score. RNA was extracted from the joint, and examined for Bv8 mRNA expression by RT-PCR and real-time RT-PCR. Synovial tissue and bone marrow were immunohistochemically examined using anti-Bv8 antibody.ResultsThe level of Bv8 mRNA expression in the joint was below the detection limit in the control group, but was elevated in the CIA group, and was correlated with the arthritis score. In addition, an increase in Bv8-positive cells was observed in the synovium and bone marrow in the CIA group.ConclusionBv8 was elevated in the synovium and bone marrow of CIA mice, suggesting that Bv8 plays an important role in the pathogenesis of arthritis.

Anti‐PM/Scl antibody‐positive dermatomyositis in a Japanese patient: a case report and review of the literature

Dear Editor, Anti-PM/Scl (polymoyositis/scleroderma) antibodies recognize two major components, PM/Scl100 and PM/ Scl75. They are detected in approximately 25% of patients with overlap syndrome of PM and systemic sclerosis (SSc), 3–13% of patients with SSc, 7–8% of patients with PM, and 1–3% of patients with dermatomyositis (DM), but these data are based on European and North American patients. The frequencies of anti-PM/Scl antibodies vary by ethnicity, and the emergence of anti-PM/Scl antibodies has been considered to be very rare in the Asian population. Here, we describe a Japanese case of DM that was positive for anti-PM/Scl antibodies and review three other previously reported Japanese cases. A 64-year-old Japanese man was referred to us with a 6-month history of erythematous plaques on his hands and a 1-month history of polyarthralgia and muscle weakness. Physical examination revealed Gottron’s lesions on the dorsal aspects of the hands and fingers (Fig. 1a) as well as the elbows and knees (Fig. 1b), mechanic’s hands, shawl sign and facial erythema (Fig. 1c). Hyperkeratotic lesions were observed on the soles. Skin sclerosis, swollen fingers and Raynaud’s phenomenon were not observed. Laboratory investigation revealed an erythrocyte sedimentation rate of 18 mm/ h, C-reactive protein of 0.27 mg/dL, creatine kinase of 140 IU/L (normal range, 62–287), aldolase of 9.9 U/L (normal range, 2.1–6.1), surfactant protein-D (SP-D) of 162 ng/mL (normal range, < 110), and KL-6 of 2582 U/mL (normal range, < 500). Antinuclear antibody test was positive at 1:160 with a nucleolar pattern, whereas anti-Sj€ ogren’s syndrome-A/B, anti-DNA, antiJo-1, anti-U1-ribonucleoprotein, anti-topoisomerase I, anti-Sm, and anti-aminoacyl transfer RNA synthetase antibodies were all negative. Using an enzyme-linked immunosorbent assay that we had developed, serum anti-Mi-2, melanoma differentiation-associated gene 5, transcription intermediary factor-1c, nuclear matrix protein 2, and small ubiquitin-like modifier activating enzyme-1 antibodies were found to be absent, while serum anti-PM/Scl100 (5.6 units) and PM-Scl75 (> 625 units) were present. A skin biopsy obtained from the nucha showed hyperkeratosis, epidermal atrophy, liquefaction degeneration, dermal edema and a perivascular lymphocytic infiltrate in the superficial dermis. Direct immunofluorescence was faintly positive for C3 and immunoglobulin M (IgM) along the dermoepidermal junction, but negative for IgG, IgA and C1q. We therefore made a diagnosis of DM. Chest computed tomography revealed ground glass opacities and reticular shadows at the base of the lower and middle lung fields bilaterally (Fig. 1). No abnormalities were detected in a screen for internal malignancy. We therefore made a diagnosis of DM with interstitial lung disease associated with anti-PM/Scl antibodies. Oral prednisolone 60 mg/day (1 mg/kg/day) and tacrolimus at 4 mg/day were administered with gradual improvement of his skin symptoms, muscle weakness, and interstitial lung disease, followed by tapering of the prednisolone dose. It is unclear whether anti-PM/Scl antibodies are present in Japanese patients with systemic autoimmune diseases because the enzyme-linked immunosorbent assay kit for anti-PM/Scl antibodies is not available in Japan. Only a small number of studies has examined the presence of anti-PM/Scl antibodies thus far. In one study of 52 Japanese patients with PM/DM, 113 with SSc and 54 with overlap syndrome, anti-PM/Scl antibodies were not detected. Furthermore, no anti-PM/Scl antibody-positive patients were found among 588 Japanese patients with SSc. Muro et al. screened the presence of anti-PM/Scl antibodies in 600 Japanese patients with various systemic autoimmune diseases. In total, 4/ 16 (25%) undifferentiated connective tissue disease patients, 3/126 (2.4%) DM patients, 1/223 (0.4%) SSc patients, and 1/88 (1.1%) Sj€ ogren’s syndrome patients were positive for anti-PM/Scl antibodies, while antiPM/Scl antibodies were not found in patients with systemic lupus erythematosus (0/123), overlap syndrome

Angiogenesis and VEGF-expressing cells are identified predominantly in the fascia rather than in the muscle during the early phase of dermatomyositis

BackgroundWe previously demonstrated that fasciitis is a common lesion in dermatomyositis (DM) and that DM-associated fasciitis is detectable, as the result of the increased vascularity in the fascia, by power Doppler ultrasonography. We aimed to investigate whether angiogenesis and vascular endothelial growth factor (VEGF)-expressing cells in the fascia are histologically demonstrated during the early phase of DM, and whether inflammation is involved in angiogenesis and an increased number of VEGF-expressing cells.MethodsWe prospectively evaluated 22 patients with DM and 11 patients with polymyositis (PM). Immunohistochemical staining for CD31, VEGF, and tumor necrosis factor-α (TNF-α) were performed on paraffin-embedded sections. The total vascular inflammation score (TVIS), angiogenesis score (AS), and numbers of VEGF-expressing and TNF-α-expressing cells were analyzed in the fascia and muscle.ResultsSignificant fasciitis was detected in most of the patients DM with or without myositis-specific/associated antibodies, while mild fasciitis was detected in four patients with PM, two of whom were positive for anti-aminoacyl-tRNA synthetase (anti-ARS) antibodies. The AS and the number of VEGF-expressing cells in the fascia of patients with DM were significantly greater than those of patients with PM; no significant difference was observed in muscle in patients with DM and PM. The number of VEGF-expressing cells in the fascia correlated with the AS of DM patients. In early-phase DM, the AS, the number of VEGF-expressing cells, and the TVIS in the fascia were significantly higher than in muscle. However, no significant differences were observed in these scores excluding the TVIS between muscle and the fascia in late-phase DM. In DM patients, the TVIS correlated with the AS in the fascia, while the number of TNF-α-expressing cells correlated with the TVIS and the number of VEGF-expressing cells in the fascia.ConclusionAngiogenesis, the number of VEGF-expressing cells, and the degree of inflammation were higher in the fascia in DM than in PM, and were increased predominantly in the fascia rather than in the muscle in early-phase DM. The degree of inflammation correlated with that of angiogenesis in the fascia of DM. The fascia can therefore be a primary site of inflammation and angiogenesis in the pathogenesis of DM.

Dr. Noda, et al reply

We appreciate the comments provided by Dr. Bhansing and colleagues1 in response to our article2. Recently, Bhansing, et al showed a significant 2-fold increase in the fascia thickness of the deltoid muscles on ultrasonography (US) in patients with dermatomyositis (DM) and polymyositis (PM) relative to healthy controls3. Additionally, they showed that the deltoid fascial thickness on US in patients with DM and PM was not associated with various clinical variables, including the disease duration, serum creatine kinase, the Health Assessment Questionnaire–Disability Index score, sex, antinuclear antibody, anti-Jo1, the subtype of idiopathic inflammatory myopathy, the clinical disease … Address correspondence to Dr. K. Noda, Division of Rheumatology, Department of Internal Medicine, the Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan. E-mail: knoda3353{at}jikei.ac.jp

AB0708 Clinical and Hepatic Histopathological Features in 13 Cases of Idiopathic Inflammatory Myopathy with Liver Damage

Background Among patients with idiopathic inflammatory myopathy (IIM), not a few cases are associated with a variable degree of liver dysfunction1,2.. Not only aspartate aminotransferase (AST) as a myogenic enzyme, but also other hepatogenic enzymes, such as alanine aminotransferase (ALT), alkaline phosphatase (ALP), γ-glutamyl transpeptidase (γ-GTP), can rise in serum of the patients. Objectives To investigate the clinical characteristics and hepatic histopathological findings in IIM. Methods We retrospectively extracted 13 adult patients who was diagnosed as IIM in our hospital and underwent liver biopsy during the period of 2007 to 2014. We evaluated the clinical, serum, and hepatic histopathological aspects. Results The case group comprised eight patients of polymyositis (PM) and five dermatomyositis (DMy). Mean age of the patients (three men and ten women) was 55.5 (24-76) years. The mean serum creatine kinase (CPK) level was 2352 (229-7515) IU/l, and the mean serum AST, ALT, ALP, and γ-GTP levels were 184.2 (42-857) IU/l, 142.3 (32-614) IU/l, 314.8 (114-601) IU/l, and 71.9 (15-250) IU/l, respectively. The histopathological findings in liver showed: two with autoimmune hepatitis (AIH) and two with primary biliary cirrhosis (PBC). All the four cases were polymyositis patients. In two out of five DMy, hepatocyte ballooning, ceroid-laden macrophage and acidophilic body were detected, but lymphocyte infiltration was very few. Another one of DMy was diagnosed non-alcoholic steatohepatitis (NASH) that also showed the hepatocyte ballooning. In addition, serum ferritin levels of these three cases were high (about 1373-1563 ng/ml) and CPK levels were relatively low (226-415 IU/l). Remaining six cases only showed non-specific mild liver damage. None of all 13 cases show normal liver histology. Conclusions This study suggested that liver inflammation occer with high frequency in IIM, but the property may differ between PM and DMy. References Matsumoto T, Kobayashi S, Shimizu H, Nakajima M, Watanabe S, Kitami N, et al. The liver in collagen diseases: pathologic study of 160 cases with particular reference to hepatic arteries, primary biliary cirrhosis, autoimmune hepatitis and nodular regenerative hyperplasia of the liver. Liver 2000; 20: 366-373 Takahashi A, Abe K, Yokokawa J, Iwadate H, Kobayashi H, Watanabe H, et al. Clinical features of liver dysfunction in collagen diseases. Hepatology Research 2010; 40: 1092-1097 Acknowledgements The authors grateful to staffs of department of rheumatology, hepatology, pathology of the Jikei University Hospital. Disclosure of Interest None declared