Naoyasu Ueda

The Cytotoxic Effects of Certolizumab Pegol and Golimumab Mediated by Transmembrane Tumor Necrosis Factor α

Background:Anti–tumor necrosis factor &agr; (anti-TNF-&agr;) agents have been successfully applied for the treatment of rheumatoid arthritis, Crohns disease, and other chronic inflammatory diseases. Not only the neutralization of soluble TNF-&agr; but also the effect on transmembrane TNF-&agr; is important mechanisms of action of anti-TNF-&agr; agents. This study investigated the cytotoxic effects of new anti-TNF-&agr; agents, certolizumab pegol and golimumab, which are mediated by transmembrane TNF-&agr;. Methods:Transmembrane TNF-&agr;–expressing Jurkat T cells that did not express TNF receptors were used. The binding ability of each anti-TNF-&agr; agent to transmembrane TNF-&agr;, antibody-dependent cell-mediated cytotoxicity, complement-dependent cytotoxicity, and the apoptotic effect were examined. Results:Certolizumab pegol and golimumab bound to transmembrane TNF-&agr;. Golimumab induced antibody-dependent cell-mediated cytotoxicity and complement-dependent cytotoxicity, which was comparable to infliximab and adalimumab. However, certolizumab pegol did not induce antibody-dependent cell-mediated cytotoxicity or complement-dependent cytotoxicity. Certolizumab pegol directly induced nonapoptotic cell death in transmembrane TNF-&agr;–expressing cells. Golimumab induced a weaker apoptotic effect than infliximab and adalimumab. Conclusions:The cytotoxic effects of anti-TNF-&agr; agents on TNF-&agr;–expressing cells are considered to be associated with the clinical effect of these agents on granulomatous diseases. The direct cytotoxic effect of certolizumab pegol on TNF-&agr;–producing cells may contribute to its clinical efficacy in Crohns disease. Golimumab may be less effective for granulomatous diseases.

Molecular mechanisms of action of anti-TNF-α agents – Comparison among therapeutic TNF-α antagonists

ABSTRACT Tumor necrosis factor (TNF)‐&agr; is a potent pro‐inflammatory and pathological cytokines in inflammatory diseases such as rheumatoid arthritis and inflammatory bowel diseases. Anti‐TNF‐&agr; therapy has been established as an efficacious therapeutic strategy in these diseases. In clinical settings, three monoclonal anti‐TNF‐&agr; full IgG1 antibodies infliximab, adalimumab, and golimumab, PEGylated Fab′ fragment of anti‐TNF‐&agr; antibody certolizumab pegol, extracellular domain of TNF receptor 2/IgG1‐Fc fusion protein etanercept, are almost equally effective for rheumatoid arthritis. Although monoclonal full IgG1 antibodies are able to induce clinical and endoscopic remission in inflammatory bowel diseases, certolizumab pegol without Fc portion has been shown to be less effective for inflammatory bowel diseases compared to full IgG1 antibodies. In addition, there are no evidences that etanercept leads clinical remission in inflammatory bowel diseases. Besides the common effect of anti‐TNF‐&agr; agents on neutralization of soluble TNF‐&agr;, each anti‐TNF‐&agr; agent has its own distinctive pharmacological properties which cause the difference in clinical efficacies. Here we focus on the distinctions of action of anti‐TNF‐&agr; agents especially in following points; (1) blocking ability against ligands, transmembrane TNF‐&agr; and lymphotoxin, (2) effects toward transmembrane TNF‐&agr;‐expressing cells, (3) effects toward Fc&ggr; receptor‐expressing cells, (4) degradation and distribution in inflamed tissue. Accumulating evidence will give us the idea how to modify anti‐TNF‐&agr; agents to enhance the clinical efficacy in inflammatory diseases.

Wegener’s granulomatosis detected initially by integrated 18F-fluorodeoxyglucose positron emission tomography/computed tomography

Early diagnosis is crucial for effective treatment of Wegener’s granulomatosis, although this disease shows only atypical symptoms in the primary stage. This report describes a patient suspected of having a malignancy based on integrated 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT), which showed increased uptake in pulmonary nodules and nasopharyngeal mucosa. Integrated PET/CT is therefore considered to be useful to confirm the distribution and determine the optimal site for biopsy.

Increased CD226 Expression on CD8+ T Cells Is Associated with Upregulated Cytokine Production and Endothelial Cell Injury in Patients with Systemic Sclerosis

Systemic sclerosis (SSc) is an autoimmune disease characterized by vascular damage and fibrosis of the skin and internal organs. Because activated and oligoclonally expanded CD8+ T cells can be detected in peripheral blood and lungs of SSc patients, effector memory CD8+ T cells may play a critical role for organ involvement in SSc; however, the pathogenic functions of effector memory CD8+ T cells remain incompletely understood. In this study, we performed DNA microarray analysis of the sort-purified effector memory CD8+ T cells from SSc patients and healthy controls, and showed that the expression of genes related to immune response and cell adhesion, including CD226 (also known as DNAX accessory molecule-1 [DNAM-1]), was significantly altered. Moreover, detailed analysis of CD226 revealed that CD226highCD8+ T cells were increased in SSc patients (mean, 50.7%) compared with healthy controls (32.9%) and were appreciably associated with the severity of skin sclerosis and interstitial lung disease. Furthermore, CD226+CD8+ T cells produced higher amount of various cytokines than CD226− ones, and CD226highCD8+ T cells from SSc patients showed upregulated IL-13 production and positive correlation with the cytotoxic capacity of CD8+ T cells against HUVECs. Finally, the neutralization of CD226 in CD8+ T cells impaired costimulation, cytokine productions, and cytolysis against HUVECs. These findings indicate that upregulated CD226 expression on CD8+ T cells reflects disease severity and is involved in SSc pathogenesis via the production of various cytokines, including profibrotic IL-13 and endothelial cell injury, and that CD226 may be a useful target in the treatment of SSc.

Clinical and Genetic Features of Patients With TNFRSF1A Variants in Japan: Findings of a Nationwide Survey

To elucidate the clinical and genetic features of patients with TNFRSF1A variants in Japan using data obtained from a nationwide survey conducted by the Ministry of Health, Labor, and Welfare of Japan study group for tumor necrosis factor receptor–associated periodic syndrome (TRAPS).

Epidemiological Studies of Specified Rare and Intractable Disease

Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) is a representative of autoinflammatory diseases. We conducted a nationwide survey for patients with TNFRSF1A variants in Japan. We obtained clinical and genetic features of 51 patients from 33 independent families. The most common variant was T61I (appearing in 49% of patients), and it was identified in 7 of 363 healthy controls. The common clinical features of Japanese patients were fever of >38 °C (100% of patients), arthralgia (59%), and rash (55%). The prevalence of abdominal pain (36%), myalgia (43%), and amyloidosis (0%) was significantly lower in Japanese patients than in Caucasian patients. Patients with TNFRSF1A variants are very rare in Japan, as in other countries, but there are a number of clinical and genetic differences between Japanese and Caucasian patients.

A Case of Multiple Venous Thromboses Associated with Acute Cytomegalovirus Infection

A previously healthy 44-year-old male presented with fever, abdominal pain, liver dysfunction and lymphadenopathy. He was diagnosed as having acute cytomegalovirus (CMV) infection with elevated CMV-IgG and IgM, and observed with supportive therapy. He was admitted to our hospital with prolonged fever lasting for a month. Enhanced CT revealed multiple thromboses in the right pulmonary artery and superior mesenteric vein. Follow-up CT after one week revealed new-onset thromboses in the left pulmonary artery and common iliac vein. Screening tests for thrombophilia were negative. His symptoms were improved with anticoagulant therapy with intravenous heparin, followed by oral warfarin. He was discharged on admission day 28 with good condition. Follow-up CT after 6 months revealed complete resolution of the thromboses. Anticoagulant therapy was stopped after 9 months, and he has been well without recurrence. Though vascular thrombosis is a rare complication, we must be alert to the signs and symptoms of thrombosis in patients with acute CMV infection.

Morvan’s syndrome and myasthenia gravis related to familial Mediterranean fever gene mutations

BackgroundWe present the first case of Morvan’s syndrome (MoS) and myasthenia gravis (MG) related to familial Mediterranean fever (FMF) gene mutations.Case presentationA 40-year-old woman with a 1-year history of bilateral ptosis and limb muscle weakness presented to our hospital. She also had memory impairment, insomnia, hyperhidrosis, and muscle twitches. Electromyography confirmed widespread myokymia, and there was evidence of temporal region dysfunction on electroencephalography. Anti-voltage-gated potassium channel complex antibodies and anti-acetylcholine receptor antibodies were both positive. Edrophonium administration was effective for bilateral ptosis and muscle weakness. She and her family experienced self-limiting febrile attacks with arthralgia, which led us to suspect FMF. Genetic analyses revealed compound heterozygous mutations in exon 2 of the MEFV gene (L110P/E148Q). From these findings, a diagnosis of MoS and MG complicated with MEFV gene mutations was made. Intravenous high-dose corticosteroids, plasma exchange, and intravenous immunoglobulin resulted in only transient, limited improvement, and frequent relapses, especially in the myasthenic symptoms. Interleukin (IL)-6, IL-1β, and tumor necrosis factor-α were markedly elevated in the serum, which was considered to be derived from the MEFV mutations and responsible for the resistance to immunotherapy.ConclusionThe present case illustrates a possible link between auto-inflammation and auto-antibody-mediated neurological diseases.

THU0063 Serum Progranulin Levels are Elevated in Dermatomyositis Patients with Acute Interstitial Lung Disease, Reflecting Severity and Prognosis

Background Recently, it has been reported that granulin (GRN) and/or progranulin (PGRN), precursor of GRN, is a soluble cofactor for TLR9 signaling [1]. We reported that serum PGRN levels are associated with SLE global activity and PGRN may have a role in the pathogenesis via increased cytokine production [2]. TLR9 is also involved in the pathological condition of dermatomyositis (DM). Moreover, DM is occasionally complicated with interstitial lung disease (ILD). However, the roles of PGRN and GRN in DM are still unknown. Objectives To determine if serum PGRN levels are elevated in DM patients, in particular, complicated with ILD and are associated with severity and prognosis. Methods The serum levels of PGRN were measured by ELISA in patients with DM (n=50; acute/subacute interstitial pneumonia (A/SIP), defined as a rapidly progressive ILD within 3 months from the onset of symptoms: n=13, chronic interstitial pneumonia (CIP): n=20, without ILD: n=17), polymyositis (PM, n=21) and normal healthy controls (NHCs, n=60). We assessed the correlation between the serum PGRN levels and the activity indexes of ILD. The sera from some of the patients were reevaluated after the disease was ameliorated by treatment (n=6). Moreover, we calculated the cumulative survival rate for 6 months in DM patients with ILD, which is classified two groups, serum PGRN levels > or =200 ng/ml and < 200 ng/ml. Results The serum PGRN levels were significantly higher in the DM patients (median: 100 ng/ml) than in the PM patients (60.4 ng/ml, P=0.0028) and NHCs (48.3 ng/ml, P<0.0001). Of the total DM patients, the levels were significantly higher in DM with A/SIP than that in DM with CIP (P<0.0001) or without ILD (P=0.0002). Proportion of clinically amyopathic DM is higher in DM with A/SIP than in DM with CIP or without ILD (76.9%, 40%, and 5.9%, respectively). The serum PGRN levels correlated significantly with serum ferritin (rs=0.71, P=0.0001), LDH (rs=0.59, P=0.0003), and CRP (rs=0.57, P=0.0005) levels. They significantly decreased following successful treatment of DM (P=0.0313). Moreover, the cumulative survival rate for 6 months was significantly lower in the group with serum PGRN levels > or =200 ng/ml (60%) than that in the group with serum PGRN levels < 200 ng/ml (P=0.001). Conclusions These findings indicate that PGRN is associated with severity and prognosis of DM with ILD. PGRN may play a role in the pathogenesis of DM by affecting the TLR9 signaling and could be a useful biomarker. References Park B, Buti L, Lee S, et al. Granulin is a soluble cofactor for toll-like receptor 9 signaling. Immunity 2011;34:505-513. Tanaka A, Tsukamoto H, Mitoma H, et al. Serum progranulin levels are elevated in patients with systemic lupus erythematosus, reflecting disease activity. Arthritis Res Ther 2012;14(6):R244. Disclosure of Interest None Declared

THU0238 Long-term follow-up of autologous hematopoietic stem cell transplantation for severe systemic sclerosis

Background Recent phase II study demonstrated that autologous hematopoietic stem cell transplantation (auto-HSCT) is more effective than conventional intravenous cyclophosphamide in the treatment of severe systemic sclerosis (SSc). However, the long-term results of CD34-selectiod or unmanipulated auto-HSCT for SSc has not been investigated. Objectives The aim of this study is to investigate the long-term results of auto-HSCT for severe SSc and to compare efficacy of CD34-selected auto-HSCT with that of unmanipulated auto-HSCT. Methods Nineteen patients (4 male and 15 female) with severe SSc were enrolled. Peripheral blood stem cells (PBSCs) were mobilized with cyclophosphamide (CY, 4 g/m2) and G-CSF. After collecting PBSCs more than 2×106CD34+cells/kg by apheresis, CD34+ cells were immunologically selected in 11 patients. All of the patients were treated with high-dose CY (200 mg/kg) and received CD34-selected (n=11; a group with CD34-selection) or unmanipulated (n=8; a group without CD34-selection) auto-HSCT. Immune reconstitution was evaluated serially by analyzing lymphocyte subpopulations for 36 months after HSCT. Results There was no treatment-related mortality. As toxicity, there were a variety of post-transplant infections such as adenoviral hemorrhagic cystitis, herpes zoster and cytomegaloviral antigenemia. Sclerosis of the skin was markedly improved in all of the patients within 6 months and the improvement was sustained for 60 months after auto-HSCT. Vital capacity was significantly increased at 48 months after HSCT and KL-6, a marker for interstitial pneumonia (IP), was significantly decreased in patients with IP during 12-60 months after HSCT. A titer of anti-Scl-70 was significantly decreased during 1-60 months after HSCT. Progression-free and overall 5-year survivals were 68 and 95%, respectively. Interestingly, the reduction of the skin scores was significantly greater and viral infections were more frequent in the patients with CD34-selection than those without. Effect of auto-HSCT on interstitial pneumonia, and the recovery of lymphocyte subpopulations after auto-HSCT were not significantly different between two groups. Conclusions Auto-HSCT had long-term effects on skin sclerosis and IP, resulting in improved prognosis in patients with severe SSc. CD34-selected auto-HSCT had greater effect on skin sclerosis than unmanipulated auto-HSCT. References Tsukamoto H, Nagafuji K, Horiuchi T, et al. A Phase I-II Trial of Autologous Peripheral Blood Stem Cell Transplantation in the Treatment of Refractory Autoimmune Disease. Ann Rheum Dis. 65: 508-14, 2006. Tsukamoto H, Nagafuji K, Horiuchi T, et al. Analysis of immune reconstitution after autologous CD34+ stem/progenitor cell transplantation for systemic sclerosis: predominant reconstitution of Th1 CD4+ T cells. Rheumatology 2011; 50: 944-52. Disclosure of Interest None Declared