Takamasa Nozaki

Epstein-Barr Virus Induces Erosive Arthritis in Humanized Mice

Epstein-Barr virus (EBV) has been implicated in the pathogenesis of rheumatoid arthritis (RA) on the basis of indirect evidence, such as its presence in affected joint tissues, antigenic cross reactions between EBV and human proteins, and elevated humoral and cellular anti-EBV immune responses in patients. Here we report development of erosive arthritis closely resembling RA in humanized mice inoculated with EBV. Human immune system components were reconstituted in mice of the NOD/Shi-scid/IL-2Rγnull (NOG) strain by transplantation with CD34+ hematopoietic stem cells isolated from cord blood. These humanized mice were then inoculated with EBV and examined pathologically for the signs of arthritis. Erosive arthritis accompanied by synovial membrane proliferation, pannus formation, and bone marrow edema developed in fifteen of twenty-three NOG mice transplanted with human HSC and inoculated with EBV, but not in the nine NOG mice that were transplanted with HSC but not inoculated with EBV. This is the first report of an animal model of EBV-induced arthritis and strongly suggest a causative role of the virus in RA.

SLAM-Associated Protein Solves a Mystery of Autoimmunity

Abstract:  SLAM‐associated protein (SAP) is essential for viral protection, lifelong immune memory (vaccination), and lifelong autoantibody production. We discuss how SAP is a key player in the development of autoimmune disease.

Efficacy and safety of minodronic acid hydrate in patients with steroid-induced osteoporosis

Minodronic acid hydrate, an oral bisphosphonate, has a greater inhibitory effect on bone resorption than do other approved drugs; however, this has been studied only in patients with primary osteoporosis. Here, we administered minodronic acid hydrate to patients with steroid‐induced osteoporosis who have been treated with steroids for rheumatoid arthritis or other collagen diseases, and the efficacy and safety of minodronic acid hydrate were prospectively investigated.

SAT0104 Subclinical Myocardial Inflammation and Fibrosis are Common in Active Rheumatoid Arthritis, Assessed by Cardiac Magnetic Resonance Imaging

Background Rheumatoid arthritis (RA) is a multi-organ inflammatory disorder associated with high cardiovascular morbidity and mortality. Importantly, cardiac involvements are typically clinically silent, only manifesting as myocardial abnormalities after an extended subclinical phase. Myocardial abnormalities may arise from a number of distinct processes, including myocardial inflammation (myocarditis), and/or myocardial fibrosis, any of which may be active in RA. Objectives We sought to assess cardiac involvement using a cardiac magnetic resonance imaging (CMR) approach and to determine its association with disease characteristics in RA patients without cardiac symptoms. Methods Consecutive RA patients and controls without cardiac symptoms were enrolled. RA patients and control subjects with no history and/or clinical findings of systemic and pulmonary hypertension, coronary artery disease, valvular heart disease, atrial fibrillation, diabetes mellitus, and dyslipidemia underwent CMR. RA patients received conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic DMARDs (bDMARDs). Late gadolinium enhancement (LGE) was obtained for the assessment of myocardial fibrosis. Using a black-blood T2-weighted image (T2-WI), myocardial inflammation could be assessed. Left ventricular geometry was classified into four categories: concentric remodeling, concentric or eccentric hypertrophy, or normal. We compared the patients and controls in terms of prevalence of CMR abnormalities, and explored possible associations between CMR abnormalities and RA disease characteristics. Results Sixty patients (mean age, 55.2±1.3 years; 85% female) and 20 controls (mean age 52.6±2.3 years; 86% female) were enrolled. Thirty RA patients received csDMARDs [25, methotrexate (MTX) (8.7±2.1mg); 5, other drugs)] and 30 RA patients received bDMARDs [(15, infliximab 3 mg/kg; 15, tocilizumab 8 mg/kg plus methotrexate (8.6±1.4 mg) mg/kg]. The control group showed no myocardial abnormalities. Twenty RA patients (33%) demonstrated myocardial abnormalities. T2-WI was seen in seven RA patients (11%). LGE was found in 19 RA patients (32%), six of whom also demonstrated T2-WI. Simplified Disease Activity Index (SDAI) scores were significantly higher in LGE-positive compared to LGE-negative (p=0.011). LGE was significantly associated with high NT-proBNP and eccentric hypertrophy (p=0.005, p=0.018, respectively). The use of bDMARDs was significantly associated with LGE-negative findings (p=0.0017). Other RA characteristics such as disease duration, autoantibody status, and cardiovascular risk factors were not significantly associated with myocardial abnormalities. After adjusting for confounding by age, RA duration, rheumatoid factor, and bDMARDs, the association of LGE with SDAI remained significant (p=0.023), in which the SDAI scores were, on average, 10.9 units higher in LGE-positive than in LGE-negative. Conclusions Subclinical myocardial inflammation and fibrosis are common in active RA patients without cardiac manifestation. Abnormal CMR findings were associated with higher RA disease activity, suggesting a role for inflammation in the pathogenesis of myocardial involvement in RA. Disclosure of Interest None declared

THU0337 Raynaud Phenomenon Is Associated with Myocardial Fibrosis in Primary Sjögren Syndrome, Assessed by A Cardiac Magnetic Resonance Approach: A Prospective Pilot Study at A Single Center

Background Primary Sjögren syndrome (pSS) shares many clinical, inflammatory, and immunological features with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Both SLE and RA are characterized by a high risk of cardiac involvement. However, there are limited data on the risk of overt cardiac involvement in pSS. Objectives We sought to use a cardiac magnetic resonance imaging (CMR) approach to assess cardiac involvement and determine its association with disease characteristics in pSS patients without cardiac symptoms. Methods Consecutive pSS patients, according to ACR classification criteria (2012), without a history or clinical findings of hypertension, cardiovascular disease, diabetes, or dyslipidemia underwent contrast CMR. Late gadolinium enhancement (LGE) was used for the assessment of myocardial fibrosis. Using a black-blood T2-weighted image (T2-WI), myocardial inflammation could be assessed. Sjögren syndrome disease activity index (ESSDAI) was determined. Eighty percent patients had documentation of a minor salivary gland biopsy. Salivary gland biopsy data were classified by focus score (FS). We investigated the patients in terms of prevalence of CMR abnormalities and explored possible associations between CMR abnormalities and pSS disease characteristics. Results Thirty-seven female pSS patients were enrolled (mean age: 55.5 ± 7.0 years). On an average, cardiovascular risk was low for the group, with patients demonstrating no ECG abnormalities, and the patients had generally low traditional cardiovascular risk factors, with a mean Framingham 10-year hard cardiovascular risk score of 4 ± 2%. The mean ESSDAI was 3.3 ± 2.1. Thirteen patients (35%) demonstrated myocardial abnormalities. Myocardial edema was seen in 5 patients (13%) on T2-WI. LGE was found in 11 patients (29%), 3 of whom demonstrated edema on T2-WI. The main finding observed in 7 among 11 LGE-positive patients (63%) was a linear LGE pattern without coronary distribution. A patchy nodular LGE pattern was observed in 4 among 11 patients (37%). The patients with CMR abnormalities showed no significant difference of ESSDAI, compared with those with no CMR abnormalities. Antibodies to La/SSB antigens were significantly higher in LGE-positive than LGE-negative patients (p=0.003). Raynaud phenomenon was significantly associated with LGE-positive and T2-WI-positive patients (p=0.001 and p=0.04, respectively). Other pSS characteristics such as disease duration, commodities, and cardiovascular risk factors were not significantly associated with myocardial abnormalities. The greatest relative difference between LGE-positive and -negative patients was observed in FS >3, with an adjusted odds ratio of 3.0. After adjusting for confounding by age, pSS duration, and anti-SSB antigen, the association of LGE with Reynaud phenomenon remained significant (p=0.02). Conclusions Subclinical myocardial involvement, as detected by CMR, was frequent in pSS patients without cardiac symptoms. Our results suggest that Raynaud phenomenon has a role in promoting cardiac involvements in patients with pSS. Disclosure of Interest None declared

Self-assembly formed by a short DNA probe pair: Application for highly sensitive mRNA species detection without reverse transcription

We describe a novel technology for detecting nucleic acids: Probe Alteration Link Self-Assembly Reactions (PALSAR). PALSAR comprises DNA self-assembly of pairs of short DNA probes formed by alternate hybridization of three complementary regions in a pair of honeycomb probes (HCPs). Self-assembly occurs at designated salt concentrations and reaction temperatures and requires no enzymes. We prepared pairs of HCPs to detect mRNAs encoded by the GAPDH gene β-actin (BA) gene, CD3D gene, CD4 gene, major vault protein (MV) gene and the signalling lymphocytic activation molecule-associated protein (SAP) gene, and succeeded in quantitatively detecting these mRNAs. PALSAR could detect mRNA directly without synthesizing cDNA. Moreover, multiple mRNAs could be detected simultaneously in a single reaction tube and there was a good correlation between the results obtained PALSAR and those by real-time PCR.

FRI0472 Detection of Left Ventricular Morphology and Myocardial Abnormalities Using Contrast Cardiac Magnetic Resonance Imaging at 3.0 Tesla in Systemic Sclerosis Without Cardiac Manifestations

Background Systemic sclerosis (SSc) has an increased prevalence of cardiac involvement despite often being clinically silent. When clinically evident, cardiac involvement decreased the 70% 5-year mortality of SSc. Cardiac magnetic resonance imaging (CMR) is useful in SSc beause it focuses on late gadolinium enhancement (LGE) abnormalities and ventricular morphology and function. Objectives We aimed to assess the prevalence of subclinical myocardial involvement by left ventricular (LV) function and structure on CMR. We evaluated the relation between myocardial abnormalities and LV geometry. Methods This study compared consecutive female SSc patients without cardiac symptoms and healthy female controls with no history or clinical findings of systemic and pulmonary hypertension by echocardiography, coronary artery disease, valvular heart disease, atrial fibrillation, diabetes mellitus, and dyslipidemia. All underwent non-contrast or contrast CMR on a 3.0-T scanner. LV function was measured using ejection fraction (EF), end-systolic volume (ESV), end-diastolic volume (EDV), stroke volume (SV), and cardiac output (CO). LV hypertrophy was measured by absolute LV mass (LVM) and LVM index (LVMI) determined by LVM/body surface area. LGE was obtained to assess myocardial fibrosis. Myocardial inflammation was assessed by black- blood T2WI. Serum BNP concentrations were measured simultaneously. Results There were 44 SSc patients with a mean age of 57.1±8.7 years; 20 had diffuse type and 24 had limited type. There were 20 healthy controls with a mean age of 56.9±3.1 years. There were no significant differences in terms of age, gender, and cardiovascular risk factors. Compared with the control, SSc patients had a significantly higher EDV with tendency towards a high LVMI. There was no difference in EF. LGE (+) was detected in 25 of 44 (57%) SSc patients; LGE was in a linear pattern without coronary distribution in 13 (52%) SSc patients. T2WI was observed in 11 of 44 (25%) SSc patients. There were no differences in LGE and T2WI between the diffuse and limited type. The BNP level of the SSc group was significantly higher than that of the control group (P=0.04). The mean BNP level of SSc patients with LGE was significantly higher than that of SSc patients without LGE (P<0.0001). BNP level in SSc patients was significantly correlated with LVMI (P<0.0001) but not correlated with EF. Eccentric hypertrophy was observed in 52% of LGE (+) patients. LGE (+) was correlated with (+) anti Scl-70 antibody (P=0.004). After adjustment for age, disease duration, anti Scl-70 antibody, and BNP, SSc with LGE did not have a modified association with LVMI. Conclusions SSc patients without cardiac symptoms have a high prevalence of cardiac abnormalities. Our data suggest that SSc-specific autoimmunity against Scl-70 mediates these changes. SSc patients with LGE had cardiac abnormalities associated with LVMI and serum BNP, leading to cardiac remodeling and possible development of cardiac involvement, even with a normal EF. Disclosure of Interest None declared

FRI0482 Cardiac Magnetic Resonance Imaging Reveals Myocardial Fibrosis and Inflammation in Polymyositis/Dermatomyositis Without Cardiac Manifestation: A Pilot Study

Background Polymyositis (PM) and dermatomyositis (DM) are inflammatory diseases; up to 70% affected patients (pts) show cardiac involvement, which may be fatal. However, the diagnosis, based on electrocardiogram, laboratory, and imaging investigations, is difficult because of nonspecific clinical presentation and the lack of standardized criteria. Cardiac magnetic resonance (CMR) is currently the best technique for diagnosing cardiac fibrosis and inflammation. Objectives To evaluate cardiac involvement in PM/DM pts without cardiac manifestations by using CMR. Methods Sixteen consecutive female PM/DM pts (age, 51.9±11.0 years; 7 DM, 9 PM) and 16 gender/age-matched healthy controls without cardiac symptoms (age, 52.6±5.3 years) underwent CMR. Pts and control subjects had no history and/or clinical findings of systemic/pulmonary hypertension, coronary artery disease, valvular heart disease, atrial fibrillation, diabetes mellitus, and dyslipidemia. Late gadolinium enhancement (LGE) was considered to indicate myocardial fibrosis, and black-blood T2WI was used for assessing myocardial inflammation. Left ventricular geometry was classified into concentric remodeling, concentric hypertrophy, eccentric hypertrophy, or normal. We compared the pts and controls regarding prevalence of CMR abnormalities, and explored the possible associations between CMR abnormalities and PM/DM disease characteristics. Group comparisons were made using the Wilcoxon chi-square test, Tukey–Kramer test, and Fisher exact test. Results PM/DM pts had normal inflammatory indices (erythrocyte sedimentation rate, C-reactive protein level), muscle enzyme assays, and improved muscle strength tests. LGE and T2WI were similar between PM and DM. LGE was seen in 8 pts (50%). Three of these 8 pts also had positive T2WI. Enhancement patterns observed were linear in middle layer, linear in subepicardial layer, nodular in middle layer, and patchy in middle layer (3, 1, 3, 1 pts, respectively). T2WI was observed in the same areas with LGE. No difference LGE positivity and T2WI findings was observed between PM (56% and 11%, respectively) and DM (43% and 29%, respectively) pts. Ejection fraction (EF) was similar between pts and controls (p=0.23). Of note, 7 pts showed concentric remodeling, and 75% of these pats showed LGE. PM/DM pts had higher NT-proBNP levels than controls. LGE was significantly correlated with concentric remodeling in PM/DM pts (p=0.04). Anti-Jo1 Ab positivity was correlated with LGE (p=0.03). However, T2WI was not associated with disease characteristics. Adjustment for disease duration, anti-Jo1 Ab, and LGE did not modify the association with concentric remodeling. Conclusions PM/DM pts without cardiac symptoms have a high prevalence of cardiac abnormalities. PM/DM pts with LGE are associated with abnormal morphology even with normal EF. Moreover, anti-Jo1 Ab positivity may be associated with LGE. Further studies are needed to determine whether CMR abnormalities affect prognosis or treatment strategy. Disclosure of Interest None declared

AB0321 IL-6 Blockade Reduces Circulating N-Terminal Pro-Brain Natriuretic Peptide Levels in Patients with Active Rheumatoid Arthritis

Background Patients with rheumatoid arthritis (RA) have a 1.5–2.0 fold higher risk of developing congestive heart failure than the general population. Small increases in N-terminal pro-brain natriuretic peptide (NT-proBNP) levels predict left ventricular (LV) dysfunction, and the LV myocardium is the primary site of NT-proBNP production. Data relating to the effects of interleukin (IL)-6 blocking agents on circulating NT-proBNP levels in patients with active RA are lacking but may be informative. To our knowledge, there are no published reports regarding the effect of tocilizumab (TCZ) treatment on NT-proBNP levels. Objectives To test the hypothesis anti-IL-6 therapy might reduce circulating NT-proBNP levels. Methods RA patients with active disease without a clinical diagnosis of cardiovascular disease (CVD) and with an inadequate clinical response to DMARDs were enrolled. The patients received TCZ once a month after 24 weeks. Serum NT-pro BNP levels were measured on the Cobas 6000 modular analyzer simultaneously on stored baseline and 24-week samples, and NT-pro-BNP levels ≥100 pg/mL were considered elevated. We explored the associations between NT-pro BNP and the RA disease activity score for 28 joints: erythrocyte sedimentation rate (DAS28-ESR) and Simple Disease Activity Index (SDAI) scores. The anti-citrullinated protein antibody (ACPA) titre was divided into high and low levels using a cut-off of 30 units/mL. Correlations between the biomarkers and changes in circulating NT-proBNP levels were evaluated using the Spearman rank test, and multivariable linear regression analyses of the correlates were performed. Results Sixty RA patients (mean age, 60.4±10.4 years; 75% female) were enrolled. The DAS28-ESR and SDAI at baseline were 4.57±1.35 and 22.5±12.7, respectively. The 24-week DAS28-ESR and SDAI scores were significantly lower than those at baseline (p=0.04, p=0.03, respectively). The NT-proBNP levels at baseline were approximately 31% higher than normal levels, and the median (interquartile range) levels significantly decreased from baseline (131.78 [52.81–230.24] pg/mL) to 24 weeks (57.13 [29.50–128.67] pg/mL, p=0.004) following TCZ treatment. The change in NT-proBNP levels was significantly correlated with the change in the SDAI score and swollen joints count (SJC) (r =0.455, p=0.003, r =0.395, p=0.004, respectively). The baseline NT-proBNP levels in the high ACPA group tended to be higher than in the low ACPA group (p=0.07). After adjustment for age, gender, ESR, and RA duration, the association between the change in NT-proBNP levels and the change in SJC remained significant (p=0.023). Conclusions The NT-proBNP level was higher than normal in patients with active RA without CVD; this may indicate subclinical left ventricular dysfunction. Furthermore, our results indicate the NT-proBNP levels decreased by approximately 38% with TCZ treatment, which was related to a reduction in disease activity. Therefore, TCZ treatment may directly influence the anti-inflammatory effect of IL-6 on the myocardium. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2189

FRI0437 How do we Treat Patients with Focus Score ≥1, but not Consistent with the New American College of Rheumatology Classification Criteria for SjÖGren's Syndrome? Evaluation from Study in Japanese Patients

Background One of the criteria for Sjögrens syndrome (SS) is focal lymphocytic infiltration in minor salivary gland biopsy (MSGB). Few studies have revealed that the proportion of patients with focus score ≥1 (FS≥1) in SS and even in the dry mouth (DM) group. Objectives To diagnose SS using the 2012 American College of Rheumatology (ACR) classification criteria for SS, to assess MSGB, and to investigate pathological features, such as FS≥1. Methods Patients underwent MSGB from September 2009 to November 2013 at one institution. The indications for MSGB included the presence of DM symptoms and serological features. Regardless of connective tissue disease (CTD) before FS evaluation, patients who met the ACR criteria were divided into: Group I, primary SS; Group II, secondary SS; Group III, secondary DM; or Group IV, primary DM (Table). We investigated the correlation between FS≥1 and the diagnosis, and the correlation of the predictor with FS≥1. Statistical analyses were performed using the Fishers exact or Mann-Whitney tests, Bonferroni multiple comparisons, and multivariate analysis. These analyses were conducted for patients with rheumatoid arthritis (RA) and those with a CTD other than RA. Results MSGBs were performed on 192 patients (93% female); those with lymphoma, IgG4-related disease, and graft-versus-host disease (7 patients) were excluded. There were 185 patients with SS and DM, including primary SS (82), secondary SS (38), DM with CTDs (22), and DM without CTDs (43). The CTDs included RA (29), systemic lupus erythematosus (15), mixed CTD (3), myositis (6), and systemic sclerosis (8). The classification of the 185 patients by diagnosis and FS≥1 is shown in the Table. More patients in Groups I and II had FS≥1 (P<0.001). Factors such as anti-Ro, anti-La, RF, and IgG correlated with the presence of FS≥1 by univariate analysis, but not by multivariate analysis. The numbers of FS≥1 were significantly different between Groups I and III, I and IV, II and III, and II and IV (all, P<0.05) but not between Groups I and II or Groups III and IV (both, P>0.08). Among the 29 RA patients, 24 had FS≥1, but SS was confirmed in 14 patients only. The numbers of RA patients with FS≥1 in both secondary SS and secondary DM group were not significantly different (P=0.134). However, among patients with CTDs other than RA, the number of patients with FS≥1 in the secondary SS group was significantly different from that in the secondary DM group (P=0.005). Even RA patients with FS≥1 were assigned to DM group. Conclusions Pathologically, FS≥1 are useful for diagnosing SS. A significant number of patients with FS≥1 was found in both the SS and DM groups. However, patients with noncharacteristic SS may also have RA. Consequently, this study suggests especially the necessity of further investigation and follow-up studies in RA patients who showed inconsistent results with the ACR criteria for DM symptoms. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2684