Stefania Sacco

Lack of HCV infection in malignant cells refutes the hypothesis of a direct transforming action of the virus in the pathogenesis of HCV-associated B-cell NHLs.

Aims and background Preliminary evidence suggests that hepatitis C virus (HCV) might play a pathogenetic role in autoimmune-related, non-malignant B-cell lymphoproliferation, as well as in a subset of B-cell non-Hodgkins lymphomas (NHLs). With regard to the mechanism(s) by which HCV might favor B-cell expansion and malignant transformation, most data support an indirect pathogenetic role of the virus as an exogenous trigger. A direct oncogenetic role of HCV by direct cell infection and deregulation has only been hypothesized on the basis of the lymphotropism of the virus. Methods In this study we investigated the possible HCV infection of NHL B cells by means of sensitive and quantitative polymerase chain reaction (PCR) on affinity-purified neoplastic cells, and by HCV-specific immunohistochemistry and in situ hybridization. Results HCV infection of neoplastic B cells was documented in only three cases, namely the low-grade B-cell NHLs that arose in the course of mixed cryoglobulinemia syndrome (MC). HCV infection, below one viral genome per cell, was detectable only by PCR. All the remaining low-grade (one case) and high-grade B-cell NHLs (two cases) were HCV uninfected. Previous immunoglobulin gene analyses were consistent with an antigen-driven B-cell lymphoproliferation in the studied cases. Conclusions Overall, our data are consistent with an indirect oncogenetic role of HCV in B-cell lymphomagenesis as an exogenous trigger. Infection of B cells by HCV appears possible in some NHL subsets, but the implications remain unknown.

Efficacy of cyclosporin-A in the long-term management of thrombocytopenia associated with systemic lupus erythematosus:

Thrombocytopenia frequently complicates systemic lupus erythematosus (SLE), and its long-term management may be problematic. Intravenous immunoglobulins and high doses of steroids are often effective as induction therapy, but thrombocytopenia frequently relapses during steroid tapering. Several immunosuppressive agents have been evaluated as induction or maintenance therapy in small series or in case reports. We describe six consecutive unselected SLE patients where cyclosporin-A (CyA) was effective and safe in the long-term management of thrombocytopenia and allowed steroid tapering. One relapse occurred during CyA reduction and responded to CyA dose adjustment. Steroids could be stopped in three out of six patients, and were maintained at very low doses in the remaining patients. CyA was stopped in one patient after one year of treatment, without relapse at month 11+ from discontinuation. No severe side effects were documented. Overall, these data suggest that CyA may prove to be an effective and safe therapeutic option for SLE-related thrombocytopenia.

Disappearance of bone marrow B cell clonal expansion in patients with type II hepatitis C virus-related cryoglobulinemic glomerulonephritis after clinical efficient rituximab therapy

Preliminary data provided encouraging results on efficacy and safety of B cell depletion with rituximab in active glomerulonephritis in the course of mixed cryoglobulinemia (MC).1 2 B cell oligomonoclonal expansion in peripheral blood and in bone marrow (BM) seems to be a key pathological and molecular feature in MC.3 4 Recently, renal involvement in MC has been associated with B cell clonal expansion in the BM.5 We report new data on the possible relationship between clinical efficacy of rituximab in MC nephritis and the disappearance of BM B cell clonal expansion after (month +6) rituximab administration demonstrated by molecular studies (fig 1).4 Figure 1 Bone marrow (BM) B cell expansion before and after rituximab. Bone marrow B cell expansion was evaluated in BM needle aspiration samples by semi-nested PCR using an upstream primer directed to the third framework variable (V) region of the IgH genes and downstream primers directed to the joining (J) region, as described previously.5 Samples were tested in duplicate, and the results were confirmed in repeated experiments. PCR products were analysed on 10% polyacrylamide gels stained with ethidium bromide. A clonal B cell expansion was defined by the presence of discrete, reproducible narrow band(s) within the predicted size range, while a polyclonal pattern by a ladder of bands with similar intensities or by the presence of weakly dominant bands, not become reproducible in repeated amplification. A monoclonal pattern of B cell expansion is shown at baseline in patients 1 and 2, and an oligoclonal pattern in patient 3. At 6 months after rituximab therapy the molecular pattern of B cell expansion had changed in all the three cases from clonal to polyclonal. Three patients, two females and one male, aged 58, 62 …

Dermoscopy of nail fold and elbow in the differential diagnosis of early psoriatic arthritis sine psoriasis and early rheumatoid arthritis

Differentiation between psoriatic arthritis (PsA) sine psoriasis and rheumatoid arthritis (RA) may be a challenge, especially in the early stages, hence the need for new instrumental markers to assist their diagnosis. In this study, we investigated possible dermoscopic differences in vascular appearance of nail fold and elbow (a classic site of repeated trauma) in these two conditions. Fifteen patients with PsA sine psoriasis, 12 patients with RA and 12 controls were included in the study. Regarding the nail fold vascular appearance in PsA sine psoriasis and RA cohorts, the presence of diffuse reddish background with or without sparse dotted vessels was significant in the former, whereas the evidence of parallel dotted/short linear vessels (“fish school‐like” pattern) or irregular/ramified, blurry, purple vessels were significant in the latter; none of these patterns were detected in the control group. Regarding the elbow, the pattern significantly associated with PsA sine psoriasis consisted of diffusely distributed, red, dotted vessels. On the other hand, RA patients and controls displayed similar dermoscopic findings, with three possible vascular patterns being observed: (i) irregular, blurry, purple vessels; (ii) avascular appearance; and (iii) sparse, dotted, purple vessels. In conclusion, dermoscopy may be a useful supportive tool for differentiating early PsA sine psoriasis from RA.

The -308 TNFα and the -174 IL-6 promoter polymorphisms associate with effective anti-TNFα treatment in seronegative spondyloarthritis.

The genetic predisposition to a long-term efficacy of anti-tumor necrosis factor (TNF)α treatment in seronegative spondyloarthritis (SpA) was investigated by analysing the possible correlation between several single nucleotide gene polymorphisms and the retention rate of anti-TNFα therapies. We compared patients needing to switch the first anti-TNFα (Sw, No. 64) within at least 12 months of follow-up with patients not needing to switch (NSw, No. 123), observing at least 6 months of treatment to establish anti-TNFα failure, leading to treatment change. Response to treatment was evaluated by standardised criteria (BASDAI for axial involvement, DAS28-EULAR for peripheral involvement). The TNFα -308 A allele and the interleukin (IL)-6 -174GG homozygosis resulted as independent biomarkers predicting survival of the first anti-TNFα therapy in SpA patients (P=0.007, odds ratio (OR): 4.4, 95% confidence interval (CI)=1.5–13.1 and P=0.035, OR: 2.1, 95% CI=1.1–4.4). Also, the male gender (P=0.001, OR: 3.4, 95% CI=1.6–7.1) associated with the NSw phenotype, whereas no association was found either with the specific diagnosis or the predominant joint involvement.

Early Psoriatic Arthritis Versus Early Seronegative Rheumatoid Arthritis: Role of Dermoscopy Combined with Ultrasonography for Differential Diagnosis

Objective. Exclusion of psoriatic skin/nail lesions is important in differentiating early seronegative rheumatoid arthritis (ERA) from early polyarticular psoriatic arthritis (EPsA) and such manifestations may go unnoticed in atypical or minimally expressed cases. The aim of this study is to assess the usefulness of integrated rheumatological-dermatological evaluation in highlighting dermatological lesions missed on rheumatological examination and to investigate the role of ultrasonography (US) and dermoscopy in improving the recognition of subclinical psoriatic findings. Methods. Patients with a new diagnosis of seropositive or seronegative ERA and EPsA with prevalent hands involvement were recruited. All were reassessed for the presence of psoriatic lesions during an integrated rheumatological-dermatological clinical evaluation and underwent hands US and proximal nailfold dermoscopy. Results. Seventy-three consecutive subjects were included in the study: 25 with seropositive ERA, 23 with seronegative ERA, and 25 with EPsA. One-fourth of the subjects initially diagnosed as seronegative ERA presented cutaneous or nail psoriasis on integrated rheumatological-dermatological evaluation, thereby being reclassified as EPsA. The presence of at least 1 extrasynovial feature on hand US and dotted vessels on proximal nailfold dermoscopy was significantly associated with EPsA, with a sensitivity of 68.0% and 96.0% and a specificity of 88.1% and 83.3% for US and dermoscopy, respectively. When used together, specificity for PsA diagnosis raised to 90.5%. Conclusion. Integrated rheumatological-dermatological clinical evaluation may be helpful in identifying patients with EPsA misclassified as seronegative ERA. Additionally, US and dermoscopy may be used as supportive tools in identifying subclinical psoriatic features, which may come in handy in distinguishing EPsA from ERA.

AB0167 ACR/EULAR Remission in Early Rheumatoid Arthritis Associates with A Shorter Time To Fulfilment The Classification Criteria and A Lower Bmi

Background A prolonged disease duration is associated to a lower chance to achieve disease remission in rheumatoid arthritis. Onset of the disease can be defined in a number of ways and, when possible, the following data should be recorded: 1) first musculoskeletal (MSK) symptoms relevant to the current compliant 2) first persistent patient-reported joint swelling 3) initial fulfilment of criteria for RA based on data obtained retrospectively1. Objectives The aim of this study was to identify the variables associated with ACR/EULAR remission2 in a cohort of early rheumatoid arthritis (ERA). In particular, the different types of disease onset, as defined1, were investigated. Methods All the patients, referred to the Early Arthritis Clinic of the University Rheumatology Clinic of Udine between October 2013 and October 2015, with a diagnosis of RA and fulfilling ACR/EULAR 2010 criteria, were included. The EULAR recommendations for treat to target were followed. At the first visit, 13 clinical and laboratory variables associated with RA, including the different type of onset1, were recorded. The variables associated with remission at the 12th month (+12) of therapy by univariate analyses were included in a multivariate logistic regression model. Receiver operator characteristic (ROC) curves were used to evaluate the discriminative capability of the different types of onset. Results Ninety-two patients with ERA were assessed and 65 completed 12-month evaluation. 15/65 (23,1%) reached ACR/EULAR remission at +12. Two variables were selected in the logistic regression analysis (i.e. BMI and time to fulfilment of ACR/EULAR classification criteria). A low BMI (OR 0,54; CI 95% 0,33 to 0,86; p=0,01) predicted remission and 23,5 being the optimal BMI cut-off value. Time to fulfilment of ACR/EULAR classification criteria for RA was also significantly associated with remission at +12 (OR 0,21; CI 95% 0,05–0,92; p=0,039) and 2,5 months was the cut-off value showing the best discriminative power for remission achievement. By contrast, a shorter time from the onset of MSK symptoms (5.5 months showing the best discriminative power) was selected only by univariate analysis. Conclusions From a clinical perspective the present preliminary data may be reassuring if confirmed by larger analyses: a shorter time from the fulfilment of ACR/EULAR classification criteria of RA, when treatment has been frequently started (thus, not necessarily the time from the onset of MSK symptoms) is associated with disease remission at +12 in ERA. From a biologic point of view, starting the treatment as soon as disease begins (i.e. onset of MSK symptoms) may be more effective, but the currently available prognostic, diagnostic and treatment tools do not allow this recommendation yet. Furthermore remission is related to BMI, since patients with BMI >24 showed a lower chance to achieve remission References Gerlag D et al. Ann Rheum Dis. 2012 May;71(5):638–41.2012; Felson DT et al. Arthritis Rheum. 2011 Mar;63(3):573–86; Disclosure of Interest None declared

THU0236 The TNF Alpha -308 and the IL-6 -174 Promoter Polymorphisms Associate with Effective Anti-TNF Alpha Treatment in Seronegative Spondyloarthritis

Background One of the most important outcomes of treatment in SpA is the retention rate of therapy in the long term. Many genetic studies in chronic polyarthritis reported a correlation between response to anti-TNF therapy and several single nucleotide polymorphisms (SNPs), but the usefulness of this finding when related to the clinical outcome is ill defined. Objectives The primary endpoint of this study was to establish a possible correlation between several genetic polymorphisms, including ones never investigated before in SpA, and the retention rate of the first TNFa blocking agent, by comparing patients needing to switch the first anti-TNFa agent (Sw) to patients not needing to switch (NSw). To distinguish these two groups, a follow-up of at least one year was required. Methods 187 consecutive SpA patients (124 males and 63 females; mean age 52±30 years) were studied. All the patients had been followed up for at least 12 months after the introduction of the first anti-TNFα agent. The mean disease duration was 30±28 years (range 2-58 years). Seventy-four (39.6%) patients were diagnosed as affected by psoriatic arthritis (PsA), 66 (35.3%) by ankylosing spondylitis (AS) and 47 (25.1%) by undifferentiated spondyloarthritis (uSpA). Six SNPs were analysed: TNFα -308A>G (rs1800629), TNFR2 196M>R, IL-6 -174G>C (rs1800795), IL-6Ra, FCGR3A 158V>F (rs396991) and TGF-beta 869T>C (rs 19822073). The chi-squared or Fishers exact test and Mann–Whitneys U-test were used. Results The TNFα and the IL-6 promoter polymorphisms were significantly associated with the NSw phenotype in SpA. In particular, the TNFα -308 AA/AG genotypes were found in 24.4% NSw vs 10.9% Sw patients (p=0.03) and the GG homozygosis of the IL-6 promoter polymorphism in 49.6% NSw vs 34.4% Sw patients (p=0.047). By multivariate analysis, the TNFα -308A allele as well as the presence of the IL-6 -174GG homozygosis resulted as independent biomarkers predicting survival of the first anti-TNFα therapy in SpA (p=0.007, OR 4.4, 95%CI 1.5-13.1, and p=0.035, OR 2.1, 95%CI 1.1-4.4, respectively). Also the male gender (p=0.001, OR 3.4, 95%CI 1.6-7.1) resulted an independent variable associated with the NSw phenotype. The other SNPs, located in the genes encoding TNFR2, IL-6Ra, TGFb and FCGR3A, did not show any significant association. No association was found between the BASDAI or DAS28 response at month +6 (for axial or peripheral involvement, respectively) and all the investigated polymorphisms. The exposure time to the anti-TNFα therapies was significantly higher in NSw in comparison with Sw (NSw: 58±25.9 months vs Sw: 30.8±20.2 months, p<0.0001); thus, the NSw group was not biased by a shorter follow-up under anti-TNFα therapy. Conclusions The TNFα -308 and the IL-6 -174 promoter polymorphisms appear significantly associated with a higher efficacy of anti-TNFa therapy in SpA, expressed by the retention rate of the first anti-TNFα agent. This confirms the importance of the genetic background to optimize the management of the biologic agents in SpA. Disclosure of Interest None declared

Use of teriparatide in osteoporosis due to active rheumatic diseases

Introduction: In inflammatory arthritis and active connective tissue diseases osteoporosis is the most frequent extra-articular clinical manifestation, associated with an high fracturative risk in trabecular bone (i.e. in lumbar spine), due to the level of disease activity, chronic corticosteroid intake and concomitant immunosuppressive therapies. Patients and methods: 28 patients (all females, age 73±6 years) suffering from severe osteoporosis (in according to OMS definition) were treated with teriparatide (a fragment of human PTH hormone) in order to FDA and AIFA indication in our rheumatology Clinic from 2005 to 2009. Eleven out of 28 pt (43%) were affected by inflammatory rheumatic diseases (active in 4/11 pt and ongoing low doses of corticosteroids in 3/11); the baseline mean number of vertebral fractures was 4.8±1.6 (median 4, range 3–9). Twenty-one pt (75%) were previously treated with one or more biphosphonates for at least 2 years. BMD (gr/cm) were evaluated with Explorer Hologic® (S/N 90954). Clinical characteristics and rheumatic disease diagnosis other than osteoporosis were reported in Table 1.