Sanae Shimamura

Post-steroid neuropsychiatric manifestations are significantly more frequent in SLE compared with other systemic autoimmune diseases and predict better prognosis compared with de novo neuropsychiatric SLE ☆

In patients with systemic lupus erythematosus (SLE), neuropsychiatric (NP) symptoms sometimes occur after administration of corticosteroids, making differential diagnosis between NPSLE and steroid-induced psychosis challenging for clinicians. The aim of this study was to clarify the characteristics of post-steroid NP disease (PSNP) in patients with SLE. Clinical courses of 146 patients with SLE and 162 with other systemic autoimmune diseases, all in the absence of NP manifestations on admission, were retrospectively analyzed. Forty-three NPSLE patients on admission (de novo NPSLE) were also investigated. All patients were consecutively recruited and treated with 40mg/day or more of prednisolone in Hokkaido University Hospital between April 2002 and March 2015. The prevalence of PSNP was strikingly higher in SLE patients than other systemic autoimmune diseases (24.7% vs. 7.4%, OR 4.09, 95% CI 2.04-8.22). As independent risk factors to develop PSNP in SLE patients, past history of mental disorder and the presence of antiphospholipid syndrome were identified using multiple logistic regression analysis. In patients with PSNP-SLE, mood disorder was significantly more frequent than in de novo NPSLE (47.2% vs. 20.9%, OR 3.38, 95% CI 1.26-9.04). Of PSNP-SLE patients, two-thirds were with one or more abnormal findings in cerebrospinal fluid, electroencephalogram, MRI or SPECT. Majority of our PSNP-SLE patients received intensified immunosuppressive treatments and experienced improvement in most cases. PSNP-SLE had better relapse-free survival than de novo NPSLE (p<0.05, log rank test). In conclusion, PSNP frequently occurred in patients with SLE and treated successfully with immunosuppressive therapy, indicating that NPSLE is likely to harbor patients with PSNP-SLE.

Surveillance for the use of mycophenolate mofetil for adult patients with lupus nephritis in Japan

Objectives. Mycophenolate mofetil (MMF) is used as one of the standard induction/maintenance protocols for lupus nephritis (LN). However, MMF has not been approved for treating LN in any country, resulting in worldwide off-label use of this immunosuppressant. In order to clarify the real-world use of MMF as a treatment for LN in Japan, Japan College of Rheumatology surveyed the use of MMF in daily clinical practice. Methods. Adult patients with LN who visited enrolled hospitals from October 2008 to September 2013 were surveyed for the initial, maximum, and maintenance doses of MMF. The safety and efficacy of MMF were retrospectively evaluated. Results. One hundred and thirty-seven LN patients including 116 females were enrolled. The median of initial, maximum, and maintenance doses of MMF were 1.0 g/day, 1.5 g/day, and 1.0 g/day, respectively. Sixty-one adverse events were reported in 39 patients during the follow-up period. Median urine protein level decreased from 1.89 g/gCr to 0.21 g/gCr, meanC3 level increased from 66.4 mg/dl to 80.3 mg/dl, and median anti-DNA antibody titer decreased from 40.6 IU/ml to 10.6 IU/ml. Conclusion. MMF was commonly used for the treatment of adult LN patients with acceptable efficacy and safety in Japan.

Three Cases of Intravascular Large B-Cell Lymphoma Detected in a Biopsy of Skin Lesions

Intravascular large B-cell lymphoma (IVL) is a rare subtype of extranodal malignant lymphoma. The proliferation of neoplastic B cells within small blood vessels causes eruptions and other symptoms in a variety of organs. The random skin biopsy is useful for diagnosing this condition in its early stages. In order to assess the diagnostic utility of this method, we examined 3 cases with the aim of comparing the occurrence of tumor cells in lesional and healthy-looking skin by performing a random skin biopsy of 32 separate sites. Our findings from the total of 32 biopsy specimens collected from the 3 cases indicated that 16 of the 17 sites on the lesional skin and 1 of the 15 sites on the healthy-looking skin were positive for neoplastic cells. This finding suggested that IVL cells occurred more frequently in the lesional skin than in the healthy-looking skin.

Prognosis and progress in immunotherapies for organ involvements in systemic autoimmune diseases.

Treatment of organ involvements accompanied by systemic autoimmune diseases is still challenging for clinicians, reminding the existence of unmet needs. Among them, lupus nephritis (LN), neuropsychiatric lupus, interstitial lung diseases (ILD) complicated with polymyositis/dermatomyositis (PM/DM) or systemic sclerosis (SSc) are the most severe conditions with poor prognosis. Because of the rarity and severity of the disease status, and of variety in evaluation methods, randomized clinical trials tend to be difficult in recruiting patients, in designing protocols, and in meeting primary endpoints. In such tough conditions, superiority of IVCY over corticosteroids alone for LN has been established, which is now going to be replaced by mycophenolate mofetil (MMF). Moreover, non-inferiority of tacrolimus to MMF is reported and efficacy of biologics such as Rituximab and Abatacept for LN is under investigation. In contrast, PM/DM-ILD is not suitable for randomized controlled trial because of the severity/acute progression in some patients. Intensive immunosuppressive regimen is recommended for those with poor prognostic factor(s). Cyclophosphamide has limited efficacy in SSc-ILD. Hematopoietic stem cell transplantation elongated patient survival and improved ILD, but with high treatment-related mortality rate. Efficacy of rituximab and MMF has been reported in small-sized trials. In this review, previously established treatment as well as emerging immunotherapies for organ involvements will be discussed. Our experiences in autoimmune settings also will be introduced.

Clinical significance of plasma presepsin levels in patients with systemic lupus erythematosus

Abstract Objectives: Presepsin (PSEP: soluble CD14 subtype) is produced from bacteria-stimulated monocytes or neutrophils, thus recognized as a biomarker of sepsis. Aberrant functions in monocyte or neutrophils are increasingly recognized in systemic lupus erythematosus (SLE). We investigated whether plasma PSEP reflects disease activity in patients with SLE. Methods: This retrospective study comprised 35 patients with SLE and 72 with non-SLE autoimmune diseases who visited our facility during the period from August 2012 to September 2015. Plasma PSEP levels and laboratory data were compared between SLE and non-SLE. Clinical markers of SLE disease activity, including SLE disease activity index 2000 (SLEDAI-2K), serum complement concentrations and serum anti-ds-DNA antibodies were assessed in correlation with plasma PSEP levels. Results: Plasma PSEP levels in SLE were higher than those in non-SLE. This phenomenon holds true when comparing SLE and non-SLE patients in the absence of infection (p = .0008). Plasma PSEP levels in SLE patients negatively correlated with C3 (r = –0.4454, p = .0430), CH50 (r = –0.4502, p = .0406) and positively with SLEDAI-2K (r = 0.4801, p = .0237). Conclusion: Elevated plasma PSEP levels were correlated with disease activity of SLE, suggesting inappropriate monocyte or neutrophil activation in the pathophysiology of SLE exacerbation.

Interferon-inducible Mx1 protein is highly expressed in renal tissues from treatment-naïve lupus nephritis, but not in those under immunosuppressive treatment

Abstract Objectives: The aim of this study was to clarify the consequences of Mx1, one of the IFN-inducible proteins, in the peripheral blood as well as in renal tissues in patients with systemic lupus erythematosus (SLE). Patients and methods: Mx1 protein concentrations in (PBMCs) from 18 SLE patients mostly in their stable disease status, 11 IgA nephropathy (IgAN) patients, 5 ANCA-associated vasculitis (AAV) patients and 16 healthy controls were measured using enzyme-linked immunosorbent assay (ELISA). Mx1 expression in renal specimens from 18 patients with lupus nephritis (LN), 18 with IgAN and 10 with AAV were evaluated using immunohistochemistry. Results: Mx1 protein concentrations in lysates of PBMCs were significantly higher in SLE patients compared with those in other three groups. Mx1-positive area in renal tissues was significantly dominant in both glomeruli and renal tubules of LN compared with other renal diseases. Renal Mx1 protein levels were lower in LN after immunosuppressive treatment, compared with those from immunosuppressant-naïve patients. Conclusion: Mx1 levels were upregulated in lupus peripheral blood even when their disease activities were stable. On the other hand, Mx1 was highly expressed in kidneys from patients with LN before treatment, which was decreased after immunosuppressive treatment. These results suggest that Mx1 is a potential marker for the diagnosis of SLE in the peripheral blood and also for the activity of lupus nephritis in the kidney.

Ectopic RASGRP2 (CalDAG-GEFI) expression in rheumatoid synovium contributes to the development of destructive arthritis

Objectives Rheumatoid arthritis (RA) is an autoimmune polyarthritis, in which fibroblast-like synoviocytes (FLS) play a key role in cartilage and bone destruction through tumour-like proliferation and invasiveness. Considering still unsatisfactory remission rate in RA even under treatment with biological disease-modifying antirheumatic drugs, novel therapeutic strategy for treatment-resistant RA is still awaited. In this study, we analysed the expression and function of Ras guanine nucleotide-releasing proteins (RASGRPs), guanine exchange factors for small GTPase Ras, in FLS as a potential therapeutic target for RA. Methods The expression of RASGRPs mRNA was quantified by a real-time PCR assay in FLS isolated from synovial tissue samples. RASGRP2 protein was also evaluated immunohistochemically. Then, we transiently transfected FLS with RASGRP2 expression vector and assessed their proliferation, adhesion, migration and invasion by cellular functional assays and downstream signalling activation using immunoblot. Finally, the therapeutic effect of RASGRP2 silencing was evaluated in type-II collagen-induced arthritis rats. Results RASGRP2 was abundantly expressed in FLS from RA synovium, whereas scarcely found in those from osteoarthritis. Expression of RASGRP2 in RA-FLS was enhanced by transforming growth factor-beta. RASGRP2 activated RAP-1, subsequently affecting nuclear factor kappa-light-chain-enhancer of activated B cells pathway and actin dynamics in FLS. RASGRP2-overexpressed FLS had increased abilities of adhesion, migration and interleukin (IL)-6 production. Silencing of RASGRP2 using the intra-articular injection of Rasgrp2-specific siRNAs dampened experimental arthritis in rats by inhibiting pannus formation. Conclusions RASGRP2 was identified to be involved in the pathogenesis of RA by promoting adhesion, migration and IL-6 production from FLS, proposed as a potential novel non-immunosuppressive therapeutic target for RA.

76 Rasgrp4 expression in rheumatoid synovium plays a critical role via ras- mapk pathway

Background and aims Ras activation as well as MAP kinase (MAPK) phosphorylation is known in the synovial tissues from patients with rheumatoid arthritis (RA). RasGRP4 is a guanine nucleotide exchange factor for small GTPase Ras and is expressed predominantly in the mast cells, monocytes and neutrophils. We previously identified ectopic expression of RasGRP4 in fibroblast-like synoviocytes (FLS) of a subset of RA patients, inducing proliferation of FLS (Kono M et al. Arthritis Rheumatol. 2015). Farnesyltransferase inhibitors (FTIs), prevent farnesylation of Ras, are known to prevent human tumour cell proliferation but the effect for proliferation of FLS is still unknown. The aim of this study is to clarify the molecular mechanisms of how RasGRP4 induces proliferation of FLS and evaluate the effect of FTI on the proliferation of FLS. Methods FLS or HEK293 cells were transfected with expression vector that encodes hRasGRP4. Phosphorylation of Raf, MEK, Erk, JNK and p38MAPK was evaluated in transfected cells using Western blotting. FLS were treated with tipifarnib, one of FTIs and cell proliferation was evaluated using BrdU Assay. Results In HEK293 cells forced to express RasGRP4, Raf-MEK-Erk pathway as well as p38MAPK was readily phosphorylated at their steady state. FLS decreased RasGRP4 expression during multiple passages. RasGRP4 transfection into such cells recovered MAPK phosphorylations, especially of Erk and p38 MAPK. FLS treated with tipifarnib down-regulated their proliferation. Conclusions RasGRP4 expression in FLS from RA patients contributes to the activation of Erk and p38MAPK signalling pathway. The inhibition of FLS proliferation by FTI was suggested as an alternative treatment in RA.

FRI0364 Usefulness of serum haptoglobin levels as a novel marker for pulmonary arterial hypertension complicated with connective tissue disease

Background Pulmonary arterial hypertension (PAH) is of great clinical significance as a life-threatening complication of connective tissue diseases (CTD). Pulmonary artery thrombotic microangiopathy (PATM) is an important pathophysiology of PAH. The concept of PATM refers to localized thrombotic microangiopathy to be defined histologically and should be discriminated from systemic thrombotic microangiopathy characterized by microangiopathic haemolysis and thrombocytopenia. The degree of PATM has been suggested to be associated with vasodilator response, severity, and prognosis of PAH, and anticoagulation therapy might be effective in PAH patients with features of PATM [1]. Haptoglobin (Hp) is a plasma protein mainly produced by hepatocytes, which binds free haemoglobin released from erythrocytes and protects the kidneys from damage induced by haemoglobin. The Hp is measured in clinical setting as a sensitive marker to detect intravascular haemolysis including thrombotic microangiopathy [2]. Objectives We hypothesized that serum Hp levels decreased in patients with PAH due to pulmonary microangiopathic haemolysis. The aim of this study was to investigate the association between serum Hp levels and pulmonary artery systolic pressure estimated by echocardiography (ePASP) in patients with CTD. Methods This study included CTD patients with suspicion of PAH who were attending Rheumatology Department in Hokkaido University Hospital between August 2015 and August 2016 and underwent echocardiography. PAH was diagnosed based on right heart catheter findings. Serum Hp levels were measured by standardised turbidimetric immunoassay in all patients. Demographic data, laboratory results, and echocardiographic findings were extracted from the medical records. Decreased serum Hp levels were defined as below 19 mg/dL based on the 95th-percentile of healthy controls. Results Twenty-four CTD patients with confirmed PAH (CTD-PAH) and 32 CTD patients without PAH (non-PAH) were enrolled. Decreased serum Hp levels were significantly frequent in patients with CTD-PAH compared with non-PAH patients (29% vs 6%, p=0.03). In patients with CTD-PAH, serum Hp levels had a significant negative correlation (r = -0.692, p<0.0001, Figure 1) with ePASP, and serum lactate dehydrogenase (LDH) levels were significantly elevated in patients with decreased Hp levels (233±47 U/L vs 187±42 U/L, p=0.01). Follow up study showed lowering ePASP led to normalizing serum Hp levels. Conclusions Serum Hp levels correlated negatively with ePASP in patients with CTD-PAH, and serum LDH levels were higher in CTD-PAH patients with decreased Hp levels. These findings suggest that decreased Hp levels in CTD-PAH patients may reflect PATM and subsequent subclinical haemolysis. Serum Hp levels are a candidate of additional non-invasive marker of CTD-PAH to assess the degree of PATM. References Johnson SR, et al. Thrombotic arteriopathy and anticoagulation in pulmonary hypertension. Chest. 2006. Barcellini W, et al. Clinical Applications of Hemolytic Markers in the Differential Diagnosis and Management of Hemolytic Anemia. Dis Markers. 2015. Disclosure of Interest None declared

Saddle nose with sarcoidosis: "A great imitator" of relapsing polychondritis.

Abstract Sarcoidosis is a systemic granulomatous disease that can affect any organ including the nose. Nasal crusting and congestion are common nasal symptoms of sarcoidosis, whereas cases of saddle-nose deformity are rarely reported. We describe here a case of sarcoidosis that presented with saddle nose resembling relapsing polychondritis. Since sarcoidosis shares clinical features with relapsing polychondritis, the differential diagnosis of saddle nose can be challenging without a clear pathology.